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be  superior  to  any  similar  books  now  on  the  market.     No 
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Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see 
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SAUNDERS'  QUESTION-COMPENDS,  No.  10. 


ESSENTIALS  OF  GYNECOLOGY. 


ARRANGED   IN    THE   FORM    OF 


QUESTIONS  AND  ANSWERS 


PREPARED    ESPECIALLY    FOR 


STUDENTS  OF  MEDICINE. 


EDWIN    B.   CRAGIN,  M.D., 

Fellow  of  the  New  York  Academy  of  Medicine,  the  New  York  Obstetrical  Society 
and  the  American  Gynecological  Society  ;  Attending  Gynecologist  to  the  Roose- 
velt Hospital,  Out-patient  Department;    Consulting  Gynecologist  to  the 
New  York  Infirmary  for  Women  and  Children;  Consulting 
Obstetrician  to  the  Maternity  Hospital,  etc. 


WITH    62    ILLUSTRATIONS. 

FOURTH  EDITION.  REVISED. 


PHILADELPHIA: 

W.    B.   SAUNDERS. 

925  Walnut  Street. 
1898. 


1?G-I// 


Copyright,  1897,  by 
W.    B.    SAUNDERS, 


PRESS   OF 
W.    B.   SAUNDERS,    PHILADA. 


PREFACE  TO  FOURTH  EDITION. 


The  favorable  reception  accorded  the  previous  edi- 
tions of  this  little  work  has  induced  the  author  once 
more  to  revise  it,  and  to  endeavor  to  harmonize  its  con- 
tents with  present  methods. 


Ul 


PREFACE  TO  FIRST  EDITION. 


No  one  appreciates  more  fully  than  the  Author  the  inadequacy  of 
this  little  work  for  a  thorough  study  of  Gynaecology.  This  has  not 
been  the  aim.  He  only  hopes  that  as  a  means  of  review  and  as  a 
summary  of  the  results  of  more  extensive  reading,  the  student  may 
find  the  work  of  some  value.  The  Author  wishes  also  to  state  that 
in  its  compilation  he  has  freely  consulted,  and  made  use  of,  the 
standard  works  of  Hart  and  Barbour,  Thomas,  Schroeder,  The 
American  System  of  Gynaecology,  notes  on  the  lectures  of  Prof 
Geo.  M,  Tuttle  at  the  College  of  Physicians  and  Surgeons,  New 
York,  ana  numerous  journals. 

E.  B.  C. 


CONTENTS. 


PAGE 

Mons  "Veneris, V7 

Labia  Majora, 17 

Labia  Minora, 18 

Clitoris, ■  18 

Vestibule, 20 

Fourchette,      20 

Fossa  Navicularis,      20 

Bulbs  of  the  Vestibule, '20 

Vulvo- vaginal  Glands, 21 

Hymen, 21 

Vagina, 21 

Uterus, 23 

Mucous  Membrane  of  Uterus, 25 

Fallopian  Tubes, 30 

Ovaries, 31 

Parovarium, 34 

Urinary  Tract, 34 

Bladder, 35 

Eectum, 37 

Pelvic  Floor, 39 

Perineal  Body, 40 

Muscles  of  the  Perineum, 41 

Ischio-rectal  Fossa, 41 

Development  of  Pelvic  Organs, 42 

Physical  Examination  of  Pelvic  Organs, 42 

Vaginal  Examination, 43 

Bimanual  Examination, 45 

Rectal  Examination,      46 

Instruments, 48 

Specula, 48 

The  Sims  Speculum, .49 

The  Simon's  Speculum, 50 

vii 


Vlll  CONTENTS. 

PAGi; 

Instruments,  the  Fergusson  Speculum, 50 

The  Brewer  Speculum,        51 

Volsella, 53 

Uterine  Sound, .  54 

Uterine  Probe, 58 

Dilators, > •  .    .  58 

Tents, 58 

Graduated  Hard  Dilators, 60 

Elastic  Dilators, 62 

The  Curette, 62 

Vulvitis, .....  63 

Acute  Simple  Catarrhal, , 64 

Chronic  Catarrhal, 64 

Gonorrhoeal, 65 

Phlegmonous, 66 

Diphtheritic, 67 

Gangrenous, ,  67 

Follicular,      G8 

Cyst  and  Abscess  of  Yulvo-vaginal  Gland, 69 

Pudendal  Hernia,    . 70 

Pudendal  Hsematocele,    . 71 

Hemorrhage  from  Vulva, 72 

Skin  Diseases  of  the  Vulva, 73 

Erythema  of  the  Vulva, 73 

Eczema  of  the  Vulva,      73 

New  Growths  of  the  Vulva, 75 

Simple  Papillomata, 75 

Pointed  Condylomata, 75 

Syphilitic  Condylomata, '  .    .    .  76 

Pruritus  Vulvae, 76 

Hypersesthesia  of  the  Vulva, 78 

Vaginismus, , 78 

Coccygodynia, 79 

Irritable  Urethral  Caruncle, 80 

Prolapse  of  Urethral  Mucous  Membrane, 81 

Malformations  of  the  Vulva, 81 

Diseases  of  the  Vagina, 82 

Simple  Catarrhal  Vaginitis, 82 

Gonorrhoeal  Vaginitis, 83 


CONTENTS.  IX 

PAGE 

Diseases  of  the  Vagina,  Ulcerative  Vaginitis, 84 

Diphtheritic  Vaginitis, 85 

Pelvic  Peritoneum,      85 

Pelvic  Peritonitis, 86 

Pelvic  Cellulitis, 88 

Pelvic  Hsematocele  and  Hsematoma, ,  92 

Menstruation, 96 

Disorders  of  Menstruation, 96 

Amenorrhoea, 96 

Vicarious  Menstruation, 98 

Menorrhagia  and  Metrorrhagia, 98 

Dysmenorrhoea, 99 

Obstructive, 100 

Congestive, 100 

Neuralgic, 101 

Ovarian, 102 

Membranous, 102 

Malformations  of  the  Vagina, 104 

Atresia  of  the  Vagina, 104 

Malformations  of  the  Uterus, 106 

Displacements  of  the  Uterus, HO 

Anteversion, HI 

Anteflexion, , 112 

Eetro version  and  Eetroflexion, 115 

Pessaries, 119 

Alexander's  Operation, 123 

Hysterorrhaphy, 124 

Prolapsus  Uteri, 125 

Laceration  of  Perineum  and  Eelaxation  of  Vaginal  Outlet,  .    .    .  128 

Hegar's  Operation, 129 

Emmet's  Operation, „    .    .    .    , 130 

Saenger-Tait  Operation,     .    . .  132 

Cleveland's  Operation, 136 

Hypertrophy  of  the  Cervix, 138 

Stenosis  of  the  Cervix, ,  140 

"^^aceration  of  the  Cervix, » 0 140 

Trachelorrhaphy,     .    .    « 143 

Endometritis,    ...-,.    o    ...    » 145 

Acute, , 145 


X  CONTENTS. 

PAGE 

Endometritis,  Chronic,    .    .    .    « , ,    .  146 

Metritis,     .    „    .    . 150 

Metritis,  Acute  Metritis, 151 

Chronic  Metritis,      152 

Atrophy  of  the  Uterus, 155 

Fibroid  Tumors  of  the  Uterus, 155 

Inversion  of  the  Uterus, 164 

Polypi, , 169 

Carcinoma  Uteri , 173 

Vaginal  Hysterectomy, 175 

Sarcoma  of  the  Uterus, 176 

Salpingitis, 177 

Affections  of  the  Ovaries, 179 

Hemorrhage  into  the  Ovaries, 179 

Ovaritis, 180 

Prolapse  of  the  Ovary, 1«3 

Tumors  of  the  Ovary, 184 

Parovarian  Cysts,     .    .* 189 

Preparation  of  Catgut,    .    .    = o 193 

Ectopic  Gestation, 194 

Fistula,      o 196 

Recto-vaginal  Fistula, 198 


ESSENTIALS  OF  GYNJICOLOGY. 


What  is  included  in  the  term  external  genitals  ? 

That  portion  of  the  genital  tract  which  is  visible  when  the  patient 
is  in  the  dorsal  position,  with  knees  elevated  and  the  labia  separated 
with  the  fingers,  viz.  :  Mons  Veneris,  Labia  Majora,  Labia  Minora, 
Clitoris,  Vestibule,  Fourchette  and  Fossa  Navicularis. 

What  other  terms  are  in  common  use  for  the  external 
genitals  ? 

Pudendum  and  Vulva. 

The  term  vulva  is  inexact,  as  it  originally  applied  to  the  labia, 
nevertheless  it  is  in  common  use. 

What  comprise  the  internal  organs  of  generation  ? 

The  Utenis,  Fallopian  tubes  and  Ovaries. 

The  Vagina  connects  the  external  with  the  internal  generative 
organs. 

Budin  regards  the  Hymen  as  anatomically  a  folding  in  of  the 
vaginal  walls. 

Mons  Veneris. 
Describe. 

The  Mons  Veneris  is  a  triangular  projection,  or  cushion  of  adipose 
tissue,  situated  over  the  symphysis  pubis.  Anatomically,  in  addition 
to  adipose  tissue,  it  contains  fibrous  and  elastic  tissue.  After 
puberty  it  is  covered  with  hair,  which  has  a  tendency  to  cui-l,  and 
is  usually  somewhat  darker  than  the  hair  of  the  head.  Numerous 
sebaceous  and  sweat  glands  are  present. 

Labia  Majora. 

Describe  them. 

The  labia  majora  are  two  folds  of  skin  which  extend  from  the 
mons  veneris  in  front  to  meet  in  the  fourchette  posteriorly ;  they 
2  17 


18  ESSENTIALS   OF  GYNECOLOGY. 

are  covered  externally  with  coarse  hair,  and  richly  supplied  with 
sebaceous  and  sweat  glands ;  they  also  contain  adipose,  fibrous  and 
elastic  tissue.  Above,  the  round  ligament  can  be  traced  into  them  on 
either  side  ;  also  the  remains  of  the  canal  of  Nuck,  which  sometimes 
continues  pervious  and  admits  of  hernia.  The  inner  surface  of  the 
labia  is  smooth,  and  somewhat  resembles  mucous  membrane,  a  few 
fine  hairs,  however,  are  visible  on  close  inspection. 

The  labia  majora  in  the  virgin  he  in  contact ;  in  old  women  they 
become  atrophied  and  allow  the  labia  minora  to  protrude. 

The  arterial  supply  is  the  superficial  perineal  branch  of  the  internal 
pudic.  The  veins  communicate  with  the  bulbs  of  the  vagina  and 
take  the  course  of  the  arteries.  The  lymphatics  empty  into  the 
inguinal  glands.  The  nerve  supply  is  from  the  supei-ficial  perineal 
branches  of  the  internal  pudic. 


Labia  Minora. 

Describe. 

The  labia  minora,  or  nymphse,  are  two  folds  of  riiuco-cutaneous 
tissue  which  arise  about  the  middle  of  the  labia  majora  on  their 
inner  surfaces,  and  extending  upward  divide  into  two  portions ;  the 
two  lower  uniting  just  below  the  clitoris  to  form  the  fraenum,  the 
two  upper  just  above  the  clitoris  to  form  the  prepuce.  The  venous 
supply  is  rich ;  it  communicates  with  the  bulbs  of  the  vagina  and 
with  the  pudic  and  perineal  veins.  The  arterial  supply,  nerves  and 
lymphatics  are  the  same  as  for  the  labia  majora.  The  sebaceous 
glands  are  very  abundant. 

Clitoris. 

Describe. 

The  chtoris,  the  analogue  of  the  penis  in  the  male,  is  situated  at 
the  apex  of  the  vestibule ;  it  consists  of  a  glans,  a  body  and  two 
crura. 

The  glans,  the  only  part  visible,  is  a  mass  of  erectile  tissue,  about 
the  size  of  a  small  pea,  very  abundantly  supplied  with  nerves  and 
partially  covered  by  its  prepuce. 

The  body  also  consists  of  erectile  tissue  ;  it  is  about  an  inch  long, 
surrounded  by  a  firm  fibrous  covering,  and  shown,  on  section,  to 


CLITORIS.  19 

consist  of  two  halves,  corpora  cavernosa,  separated  by  an  imperfect 
septum. 

The  crura  are  two  prolongations  of  erectile  tissue  with  a  dense 
fibrous  sheath ;  they  arise  from  the  anterior  borders  and  inner  sur- 
faces of  the  pubic  and  ischiatic  rami,  and  extend  forward  to  unite 
m  the  body  just  beneath  the  pubic  arch. 

Give  the  vascular  supply  of  the  clitoris. 

The  arterial  supply  is  from  the  two  terminal  branches  of  the  in- 
ternal pudic.  The  blood  is  returned  by  the  dorsal  vein  which  empties 
into  the  vesical  plexus. 

Describe  the  lymphatics  of  the  clitoris. 

The  clitoris  is  surrounded  by  a  plexus  of  lymphatics  which  termi- 
nate in  the  inguinal  glands. 

Describe  the  nerve  supply  of  the  clitoris. 

The  clitoris  receives  numerous  filaments  both  from  the  sympa- 
thetic system  and  from  the  pudic  nerve. 

According  to  Savage,  "small  as  this  organ  is  compared  with  the 
penis,  it  has  in  proportion  four  or  five  times  the  nervous  supply  of 
the  latter." 

What  are  the  diiFerences  between  the  clitoris  and  the  penis  ? 

The  clitoris  has  neither  corpus  spongiosum  nor  urethra,  both  of 
which  are  present  in  the  penis. 

What  are  the  points  of  resemblance  between  the  clitoris  and 
the  penis  ? 

They  are  both  erectile. 

They  each  consist  of  a  glans,  a  body  and  two  crura. 

They  each  have  two  corpora  cavernosa  separated  by  an  incomplete 
septum.  The  glans  in  each  is  partly  covered  by  a  prepuce,  with 
its  fraenum  attached  below. 

What  do  we  find  in  the  female  as  the  analogue  of  the  corpus 
spongiosum  in  the  male  ? 

The  bulbs  of  the  vestibule  and  the  labia  minora,  which,  in  the 
female,  lie  at  the  side  of  the  urethra,  correspond  to  the  corpus 
spongiosum  in  the  male. 


20  ESSENTIALS   OF   GYNECOLOGY. 

What  in  the  male  is  the  analogue  of  the  labia  major  a  in 
the  female? 
The  scrotum. 

Vestibule. 

Describe. 

The  vestibule  is  a  triangular  area  covered  with  mucous  membrane, 
in  the  base  of  which  is  situated  the  meatus  urinarius  ;  the  apex  lies 
just  below  the  clitoris  ;  the  sides  are  formed  by  the  inner  edges  of 
the  labia  minora,  the  base  by  the  upper  margin  of  the  vaginal 
orifice.  Beneath  the  mucous  membrane  lies  a  venous  plexus  called 
the  pars  intermedia.  The  vestibule  differs  from  the  labia  and  mons 
veneris  in  having  no  sebaceous  glands. 

Fourchette. 

Describe. 

The  fourchette,  or  posterior  commissure,  is  a  mere  fold  of  skin 
formed  by  the  junction  of  the  labia  majora  at  the  anterior  edge  of 
the  perineum. 

Fossa  Navicularis. 
Describe. 

The  fossa  navicularis  is  a  boat-shaped  cavity  which  is  formed 
between  the  lower  portion  of  the  hymen  and  the  inner  aspect  of 
the  fourchette,  when  the  latter  is  pulled  down  with  the  finger,  or 
the  labia  are  separated. 

When  the  parts  are  at  rest,  no  such  hollow  exists. 

Bulbs  of  the  Vestibule. 

Describe  them. 

The  bulbs  of  the  vestibule  are  two  oval  masses  of  erectile  tissue 
situated  on  either  side  of  the  ostium  vaginae  and  base  of  the  vesti- 
bule ;  posteriorly,  they  lie  in  contact  with  the  anterior  layer  of  the 
triangular  ligament ;  they  are  partially  covered  in  front  by  the  bulbo- 
cavernosi  muscles  ;  they  extend  as  high  as  the  meatus  urinarius,  and 
are  connected,  by  the  pars  intermedia  with  the  cavernous  tissue  of 
the  clitoris.  Their  size  varies  greatly  from  that  of  a  bean,  as  given 
by  Hart  and  Barbour,  to  a  mass  an  inch  and  a  half  long. 


VAGINA. 


Vulvo-Vaginal  Glands. 

Describe. 

The  vulvo-vaginal,  or  Bartholinian  glands  are  small  oval  bodies 
about  tbe  size  of  an  almond,  lying  just  behind  the  lower  extremities 
of  the  bulbs  ;  they  lie  behind  the  anterior  layer  of  the  triangular 
ligament,  and  each  gland  has  a  duct  about  half  an  inch  in  length 
which  opens  just  in  front  of  the  hymen  on  each  side. 

They  secrete  a  glairy  mucus  which  lubricates  the  parts. 


Hymen. 

Describe. 

The  hymen  is  a  fold  of  mucous  membrane  which  surrounds  the 
ostium  vaginse  ;  it  has  a  connective  tissue  framework,  and  contains 
blood  vessels  and  nerves. 

According  to  Budin,  it  is  an  infolding  of  the  entire  vaginal  wall. 

The  hymen  may  be  of  several  forms  ;  the  most  common  being  the 
crescentic.  Other  forms  are  the  annular,  making  a  ring  about  *,he 
ostium ;  the  cribriform,  perforated  by  numerous  small  holes ;  and 
the  fimbriated,  with  a  fringed  edge.  It  is  sometimes  imperforate, 
a  pathological  condition. 

What  value  has  the  hymen  as  a  criterion  of  chastity  ? 

Very  sHght,  as  neither  is  its  absence  proof  that  intercourse  has 
taken  place,  nor  is  its  presence  an  absolute  proof  to  the  contraiy. 

What  are  the  carunculse  myrtiformes  ? 

In  women  who  have  borne  children .  there  are  found  papillary 
elevations  surrounding  the  vaginal  orifice.  These  are  the  remains 
of  the  hymen,  and  are  called  carunculae  myrtiformes. 

Vagina. 
Describe. 

The  vagina  is  spoken  of  by  Hart  and  Barbour  as  "a  mucous  slit  in 
the  pelvic  floor;"  it  is  the  canal  connecting  the  uterus  and  the 
vulva,  lying  between  the  bladder  and  urethra  in  front  and  the 
rectum  behind ;  its  walls,  which  are  anterior  and  posterior,  are 
normally  in  contact. 


22  ESSENTIALS   OF   GYNECOLOGY. 

The  anterior  wall  measures  2-2J  inches  in  length,  the  posterior 
3-3 J  inches.  The  anterior  wall  is  shorter  than  the  posterior,  from 
the  fact  that  the  uterus  is  set  into  the  anterior  wall. 

The  vagina  is  very  dilatable,  and  when  distended  is  conical  in 
shape,  being  much  more  roomy  above  than  below. 

The  vaginal  walls  on  section  are  seen  to  consist  of  three  layers : 
1,  mucous  ;  2,  muscular  ;  3,  connective  tissue. 

The  mucous  membrane  on  both  anterior  and  posterior  walls  presents 
at  the  lower  portion  of  the  canal  numerous  ridges  or  rugae,  extending 
transversely  from  a  central  column ;  the  anterior  being  the  more 
distinct.  The  epithelium  covering  the  mucous  membrane  is  of  the 
squamous  variety. 

The  muscular  coat  consists  of  two  layers  of  unstriped  muscle,  the 
outer  being  longitudinal  and  the  inner  circular. 

The  outer  coat  is  of  connective  tissue,  and  contains  the  external 
plexus  of  veins. 

The  roof,  or  fornix  of  the  vagina,  that  portion  of  the  canal  sur- 
rounding the  cervix,  is,  for  convenience,  divided  into  four  portions : 
the  anterior  fornix,  the  posterior  fornix,  and  the  lateral  fornices; 
of  these  the  posterior  is  the  deepest.  A  very  few  mucous  glands  are 
found  in  the  vagina.     The  secretion  is  an  acid  mucus. 

What  is  the  arterial  supply  of  the  vagina  ? 

The  arterial  supply  is  from  the  vaginal  arteries,  which  supply  the 
lateral  walls  ;  branches  of  the  uterine  arteries  supplying  the  upper 
portion,  and  branches  of  the  pudendal  arteries  the  lower.  These 
anastomose  with  each  other  and  with  the  vesical  and  rectal 
arteries. 

Describe  the  veins  of  the  vag-ina. 

The  vaginal  veins  form  plexuses  which  surround  the  canal  like 
sheaths ;  one  being  external  to  the  muscular  layer,  the  other  just 
beneath  the  mucous  membrane. 

"These  communicate  freely  with  the  pudendal,  vesical  and  hemor- 
rhoidal plexuses  below,  and  with  the  plexuses  of  the  broad  ligament 
above."     These  veins  contain  no  valves. 

Describe  the  lymphatics  of  the  vagina. 

The  lymphatics  of  the  lower  fourth  of  the  vagina,  together  with 
those  from  the  external  genitals  enter  the  inguinal  glands. 


UTERUS.  23 

The  lymphatics  from  the  upper  three-fourths  of  the  vagina  join 
with  those  from  the  ceiTix  and  bladder,  and  enter  the  iliac  glands. 
According  to  Le  Bee,  they  enter  the  obturator  glands. 

Describe  the  nerve  supply  of  the  vagina. 

The  vagina  is  supplied  by  branches  of  the  inferior  hypogastric 
plexuses  of  the  sympathetic  system.  These  plexuses  lie  on  either 
side  of  the  vagina. 

Give  the  relations  of  the  vagina. 

The  anterior  vaginal  wall  is  connected  in  its  lower  half  with  the 
urethra,  in  its  upper  half  with  the  neck  and  fundus  of  the  bladder ; 
the  former  connection  is  much  more  intimate  than  the  latter.  The 
posterior  vaginal  wall  in  its  lower  fourth  lies  in  connection  with  the 
perineal  body,  in  its  middle  two-fourths  with  the  rectum,  in  its  upper 
fourth  with  the  cul-de-sac  of  Douglas.  The  anterior  fornix  is  distant 
H  inches  from  the  utero-vesical  pouch,  and  through  this  fornix  can 
normally  be  felt  the  body  of  the  uterus  and  the  angle  it  makes  with 
the  cervix. 

The  posterior  fornix  is  in  contact  with  the  cul-de-sac  of  Douglas. 
The  lateral  fornices  are  in  relation  with  the  bases  of  the  broad  liga- 
ments, and  through  these  fornices  can  normally  be  felt  the  vessels  of 
the  broad  ligament,  and  occasionally  the  ovaiy  and  tube  of  that  side. 

The  vagina  makes  an  angle  of  60°  with  the  horizon  when  the 
woman  is  erect. 

Uterus. 
Give  the  gross  anatomy. 

The  uterus,  the  organ  of  gestation,  is  a  hollow,  pear-shaped  organ, 
flattened  antero-posteriorly,  situated  in  the  pelvis  between  the  bladder 
and  rectum.  It  measures  in  the  virgin  about  3  inches  in  length,  2 
inches  in  breadth,  at  the  level  of  the  Fallopian  tubes,  and  one  inch 
in  thickness.     The  weight  of  the  virgin  uterus  varies  from  1  to  li^  oz. 

It  consists  of  three  portions  :  the  cervix,  body  and  fundus. 

As  viewed  externally,  the  uterus,  on  its  anterior  surface,  is  nearly 
flat,  its  posterior  surface  convex  ;  a  little  below  the  centre  is  a  slight 
constriction  called  the  isthmus. 

The  cervix  is  that  portion  of  the  uterus  below  the  isthmus,  and 
which  projects  in  part  into  the  vagina. 


24  ESSENTIALS   OF   GYNECOLOGY. 

The  body  is  that  portion  between  the  isthmus  and  the  hne  joining 
the  entrance  of  the  Fallopian  tubes. 
The  fundus  is  the  portion  above  this  line. 

Describe  the  uterine  canal. 

The  uterine  canal  measures  normally  2|  inches,  and  holds  about 
12  drops ;  the  cemcal  portion  of  the  canal  is  spindle-shaped  ;  the 
remainder  is  triangular,  with  anterior  and  posterior  walls  in  contact. 

What  are  the  openings  into  the  uterine  cavity  ? 

There  are  three  :  the  os  externum,  which  communicates  with  the 
vagina  ;  and  the  orifices  of  the  Fallopian  tubes  at  the  upper  angles. 


Fig.  1. 


Diagram  of  Utems,  to  show  divisions  of  Cervix.    (Schroeder.) 

a,  Infra-vaginal  portion;  ?>,  Intermediate   portion;    c,  Supra-vaginal  portion;   Bl, 

Bladder ;  P,  Peritoneum.    The  dotted  line  shows  peritoneum. 

which  connect  the  uterine  with  the  peritoneal  cavity.     The  os 
internum  connects  the  cavity  of  the  cervix  with  that  of  the  body. 

What  divisions  of  the  cervix  are  made  ? 

Schroeder  divides  the  cervix  into  three  portions,  as  seen  from  the 
accompanying  figure,  (Fig.  1,  a,  6,  c). 

a.  The  infra-vaginal  portion. 

b.  The  intermediate  portion. 

c.  The  supra-vaginal  portion. 


]MITCOUS  MEMBRANE  OP  THE  UTERUS.  25 

Tlie  infra-vaginal  portion  of  the  cervix  (a)  is  that  below  the  level 
of  the  attachment  of  the  anterior  vaginal  wall. 

The  supra-vaginal  p(jrtion  (c)  is  that  above  the  level  of  the  attach- 
ment of  the  posterior  vaginal  wall. 

The  intermediate  portion  (b)  is  that  between  the  infra-  and  supra- 
vaginal portions. 

What  portions  of  the  cervix  project  into  the  vagina  ? 

The  infra-vaginal  portion  of  the  anterior  lip,  and  the  infra-vaginal 
and  intermediate  portions  of  the  posterior  lip. 

For  practical  purposes,  it  is  sufficient  to  divide  the  cervix  into  the 
supra-vaginal  portion,  that  above  the  attachment  of  the  vagina ; 
and  the  infra-vaginal,  that  within  the  vagina. 

What  are  the  three  elements  in  the  structure  of  the  uterus  ? 

1.  The  mucous  membrane. 

2.  The  muscular  coat. 

3.  The  peritoneal  coat. 

Mucous  Membrane  of  the  Uterus. 

Describe  that  of  the  cervix. 

The  mucous  lining  of  the  cervix  differs  from  that  of  the  body  of 
the  uterus.  In  the  cervix  it  is  thrown  into  folds  presenting  the 
arbor  vitaB  appearance,  there  being  a  central  ridge  on  both  anterior 
and  posterior  walls,  and  from  these 'ridges  secondary  ridges  extend- 
ing obliquely. 

The  anterior  and  posterior  ridges  are  not  directly  opposite,  but  fit 
past  one  another.  The  epithelium  is  cihated  on  the  ridges,  non- 
ciliated  in  the  depressions  (de  Sinety). 

The  mucous  membrane  covering  the  vaginal  portion  of  the  cervix 
closely  resembles  that  of  the  vagina,  consisting  of  vascular  papillae 
covered  by  squamous  epithelium. 

Describe  the  mucous  membrane  of  the  body  of  the  uterus. 

The  mucous  lining  of  the  body  of  the  uterus  is  smooth,  velvety 
and  of  a  grayish  red  color  ;  it  is  directly  connected  with  the  muscu- 
lar coat,  with  no  submucous  layer.  It  averages  about  ^  of  an  inch 
in  thickness,  and  consists  of  columnar,  ciliated  epithelium,  on  a  base 
of  connective  tissue  between  whose  fibres  numerous  lymph  spaces 


26  ESSENTIALS   OF  GYNECOLOGY. 

are  found.  The  mucous  membrane  is  thickly  studded  with  glands, 
the  utricular  glands,  which  penetrate  the  whole  thickness  of  the 
mucous  layer.  These  glands  are  of  the  tubular  variety,  and  are  fre- 
quently bifurcated  at  their  blind  extremities.  They  are  lined  with 
prismatic  ciliated  epithelium,  resting  on  a  thin  membrana  propria. 
Their  direction  is  not  at  right  angles  to  the  surface,  but,  according 
to  Turner,  more  or  less  oblique. 

Describe  the  muscular  structure  of  the  uterus. 

The  muscular  structure  of  the  uterus  is  most  marked  after  im- 
pregnation ;  it  can  then  be  separated  into  three  layers  : — 

1.  The  external  or  longitudinal. 

2.  The  middle  or  oblique, 

3.  The  internal  or  circular. 

The  external  layer  is  most  distinct  on  the  anterior  and  posterior 
surfaces,  where  it  is  seen  to  consist  of  fibres  running  up  longitudi- 
nally over  the  fundus  ;  it  sends  fibres  into  the  broad,  round,  ovarian 
and  utero-sacral  ligaments  and  also  into  the  Fallopian  tubes. 

The  middle,  or  oblique  layer  has  no  regular  arrangement ;  some  of 
the  fibres  run  longitudinally,  some  transversely  and  some  obliquely ; 
they  surround  the  blood  vessels,  and  on  this  account  this  layer  is  of 
great  importance  ;  it  constitutes  the  chief  portion  of  the  uterine  wall. 

The  internal  or  circular  layer  shows  fibres  arranged  in  a  circular 
manner,  most  distinct  around  the  orifices  of  the  Fallopian  tubes  and 
at  the  OS  internum. 

Describe  the  peritoneal  coat  of  the  uterus. 

The  peritoneum  covers  the  anterior  surface  of  the  uterus  above 
the  level  of  the  internal  os  ;  it  extends  over  the  fundus,  covers  its 
posterior  surface  as  low  as  the  attachment  of  the  posterior  vaginal 
wall,  and  extends  down  the  latter  for  about  an  inch. 

Describe  the  arterial  supply  of  the  uterus. 

The  uterus  is  supplied  by  the  uterine  and  ovarian  arteries,  as  seen 
by  the  accompanying  figure.     (Fig.  2. ) 

The  uterine  artery  arises  from  the  anterior  division  of  the  internal 
iliac,  runs  between  the  folds  of  the  broad  ligament  to  about  the 
level  of  the  os  externum,  and  then  turns  upward  along  the  side  of 
the  uterus  to  unite  with  the  descending  branch  of  the  ovarian  artery ; 


MUCOUS   MEMBRANE   OF  THE  UTERUS. 


27 


it  gives  off  rmmerous  lateral  branches  to  the  uterus,  anastomosing 
with  those  of  the  opposite  side  ;  these  are  very  tortuous  and  are 
called  the  "  curHng  arteries  of  the  utems." 


Fie.  2. 


Distribution  of  ovarian,  uterine  and  vaginal  arteries  {HyrlT). 

a,  ovarian  artery;  a' and  h\  branches  to  tube  ;  c',  branches  to  ovary  ;  h,  branch  to 

round  ligament;  c,  branch  to  fundus;  d,  branch  to  join  uterine  artery  ;  e,  uterine 

artery ;  /,  anterior  branch  of  internal  iliac;  a,  vaginal  arteries  ;  A,  azygos  artery 

of  vagina.  >  ;/>      e.  ,    .      js  3 


28  ESSENTIALS   OF   GYN^COLOaY. 

Sometimes  the  vaginal  artery  springs  directly  from  the  uterine. 

Opposite  the  internal  os,  the  uterine  artery  gives  off  a  branch 
which,  uniting  with  its  fellow  of  the  opposite  side,  surrounds  the 
cervix  and  is  called  "the  circular  artery." 

The  ovarian  artery  arises  directly  from  the  aorta,  runs  between  the 
folds  of  the  broad  ligament,  at  its  upper  part,  to  the  upper  angle  of 
the  uterus ;  it  gives  off  a  few  large  vessels  to  the  outer  extremity  of 
the  tube,  and  then  a  number  of  very  tortuous  vessels  which  sur- 
round the  ovary. 

Just  before  reaching  the  uterus,  it  gives  off  a  number  of  branches 
to  the  proximal  extremity  of  the  tube  and  one  to  the  round  liga- 
ment. 

At  the  angle  of  the  uterus  it  divides  into  two  branches  ;  one  sup- 
plies the  fundus  and  anastomoses  with  its  fellow  of  the  opposite 
side ;  the  other  descends  along  the  side  of  the  uterus  and  anasto- 
moses with  the  uterine  artery. 

The  arterial  supply  of  one  side  alone  has  been  described,  but  the 
description  applies  equally  well  to  the  other  side. 

Describe  the  venous  supply  of  the  uterus. 

The  uterus  is  surrounded  beneath  the  peritoneum  by  a  plexus  of 
veins,  called  the  uterine  plexus ;  this  receives  the  blood  from  the 
uterine  walls  and  communicates  with  the  vaginal  and  vesical  plexuses 
below  and  the  pampiniform  above ;  it  empties  into  the  internal  iliac 
and  ovarian  veins. 

Describe  the  lymphatics  of  the  uterus. 

The  lymphatics  from  the  body  of  the  uterus  join  with  those  from 
the  ovary  and  tube  and  terminate  in  the  lumbar  glands. 

The  lymphatics  from  the  cervix  pass  beneath  the  base  of  the 
broad  ligaments  to  the  iliac  glands. 

According  to  Le  Bee,  they  terminate  in  the  obturator  glands. 

Give  the  nerve  supply  of  the  uteruso 

The  chief  nerve  supply  of  the  uterus  is  from  the  inferior  hypo- 
gastric plexus  of  the  sympathetic. 
The  cervix  also  receives  branches  from  the  upper  sacral  nerves. 

What  is  the  normal  position  of  the  uterus  ? 

This  questiop  has  been  frequently  discussed  and  at  great  lengtli. 


MUCOUS  MEMBRANE  OF  THE  UTERUS.  29 

It  is  now  sufficient  for  praxjtical  purposes  to  say  that  tlie  uterus, 
when  the  pelvic  organs  are  normal  and  when  bladder  and  rectum  are 
empty,  lies  slightly  anteflexed  and  slightly  anteverted  ;  hut  the  posi- 
tion is  constantly  changing  with  the  degree  of  distention  of  the  blad- 
der and  rectum,  especially  the  former. 

What  are  the  ligaments  of  the  uterus  ? 

There  are  two  utero-vesical  ligaments,  two  round,  two  broad  and 
two  utero-sacral. 

Describe  the  utero-vesical  ligaments. 

They  are  two  folds  of  peritoneum  passing  between  the  bladder  and 
the  lower  portion  of  the  uterus  on  each  side. 

Describe  the  round  ligaments. 

They  are  two  musculo-fibrous  cords,  4-5  inches  in  length,  which 
extend  from  the  superior  angles  of  the  uterus,  in  the  anterior  folds 
of  the  broad  ligaments  and  below  the  Fallopian  tubes,  forward  and 
outward  to  the  inguinal  canal ;  thence  through  this  canal  where  they 
terminate  in  three  points  of  insertion  :  the  external,  middle  and 
internal.  The  external  blends  with  the  outer  pillar  of  the  ring  near 
Gimbemat's  ligament.  The  middle  terminates  in  the  upper  portion 
of  the  external  ring.  The  internal  unites  with  the  conjoined  tendon. 
Besides  muscular  and  fibrous  tissue,  these  ligaments  contain  areolar 
tissue,  vessels  and  nerves. 

They  are  of  importance  surgically  as  being  those  shortened  in 
operations  for  the  correction  of  posterior  displacements. 

Describe  the  broad  ligaments. 

They  are  two  folds  of  peritoneum  which  extend  from  the  sides  of 
the  uterus  to  the  wall  of  the  pelvis,  ' '  along  a  line  which  is  situ- 
ated between  the  great  sacro-sciatic  notch  and  the  margin  of  the 
obturator  foramen  as  far  down  as  the  level  of  the  ischial  spine. ' ' 
The  inner  and  greater  part  of  its  superior  border,  on  each  side,  Is 
occupied  by  the  Fallopian  tube  ;  the  part  of  the  superior  border  not 
so  occupied  is  called  the  infandibulo-pelvic  ligament. 

What  two  folds  are  made  in  the  broad  ligament  in  addition 
to  that  occupied  by  the  Fallopian  tube  ? 
An  anterior  fold  caused  by  the  round  ligament  and  a  posterior  fold 
caused  by  the  ovarian  ligament. 


30  ESSENTIALS   OF   GYNECOLOGY. 

Describe  the  ovarian  ligament. 

It  is  a  fibro-muscular  cord  about  an  incli  in  length,  which  connects 
the  ovary  with  the  side  of  the  uterus,  just  below  the  entrance  of  the 
Fallopian  tube.  It  lies  in,  and  is  surrounded  by,  the  posterior  fold 
of  the  broad  ligament. 

What  are  contained  between  the  folds  of  the  broad  ligament 
on  either  side  ? 

The  round  ligament.  Fallopian  tube,  ovarian  ligament,  the  paro- 
varium, cellular  tissue,  uterine  and  ovarian  arteries,  the  pampiniform 
plexus  and  other  veins,  numerous  lymphatics  and  nerves. 

The  ovary  is  attached  to  the  anterior  fold  of  the  broad  ligament 
and  projects  through  the  posterior  fold. 

Describe  the  utero-sacral  ligaments. 

They  are  folds  of  peritoneum  containing  muscular  and  cellular  tis- 
sue, which  extend  from  the  lower  part  of  the  sides  of  the  uterus, 
backward  and  outward  to  the  second  sacral  vertebra. 

What  is  the  meaning  of  the  term  "uterine  appendages,'*  as 
usually  employed  ? 

The  Fallopian  tubes  and  ovaries. 

Fallopian  Tubes. 

Describe  them. 

They  are  two  tubes  3-5  inches  in  length,  which  extend  laterally 
from  the  superior  angles  of  the  uterus  ;  they  lie  within  the  folds  of 
the  broad  ligaments,  and  their  direction  is  first  outward,  then  for- 
ward, backward  and  inward  toward  the  ovary. 

They  are  divided  for  consideration  into  three  portions  :  the  isth- 
mus, the  ampulla  and  the  fimbriated  extremity. 

The  isthmus  is  the  narrowest  portion  ;  it  measures  about  an  inch 
in  length,  and  extends  from  the  angle  of  the  uterus  directly  outward, 
joining  the  ampulla  ;  its  lumen  is  only  large  enough  to  admit  a  fine 
bristle. 

The  ampulla  is  the  curved,  dilated  portion  of  the  tube  ;  its  lumen 
admitting  an  ordinary  uterine  sound. 

The  fimbriated  extremity  (infiindibulum)  is  the  expanded,  funnel- 
shaped  outer  end,  which  is  surrounded  by  fringe-like  processes  (fim- 


OVARIES.  31 

briae),  both  primary  and  secondary,  the  latter  arising  from  the 
former,  which  are  4-5  in  number.  The  longest  of  the  primary 
fimbriae  lies  to  the  inner  side,  is  grooved,  and  is  attached  to  the 
ovary  ;  this  is  called  the  fimbria  ovarica. 

The  tubes,  on  section,  are  seen  to  consist  of  four  layers  or  coats  ; 
the  peritoneal  coat ;  two  muscular  coats,  the  outer  being  longitudinal, 
the  inner  circular  ;  and  a  mucous  coat. 

There  is  no  submucous  layer. 

The  mucous  membrane  is  thrown  into  longitudinal  folds  ;  the  epi- 
thelium is  columnar  and  ciliated. 

Give  the  arterial  supply  of  the  Fallopian  tubes. 

The  Fallopian  tubes  are  supplied  by  the  ovarian  arteries,  which 
send  branches  directly  to  the  outer  and  inner  portions  of  the  tube 
and  supply  the  middle  third  through  branches  from  the  plexus 
about  the  ovary. 

"Describe  the  veins,  lymphatics  and  nerve  supply  of  the  Fal- 
lopian tubes. 

The  veins  of  the  tubes  enter  the  pampiniform  plexus  on  either 
side. 

The  lymphatics  join  with  those  from  the  upper  part  of  the  uterus 
and  from  the  ovary,  and  terminate  in  the  lumbar  glands. 

The  nerve  supply  is  from  the  inferior  hypogastric  plexuses. 

What  is  the  supposed  direction  of  the  current  in  the  motion 
of  the  cilise  of  the  epithelium  in  the  uterus  and  tubes  ? 

In  both  cases  toward  the  fundus  ;  in  the  uteiiis,  from  below 
upward ;  in  the  tubes,  from  the  fimbriated  extremity  toward  the 
uterus. 

Ovaries. 

Give  their  gross  anatomy. 

The  ovaries  are  two  ' '  flattened  ovoid ' '  bodies  lying  in  the  plane " 
of  the  brim  of  the  pelvis,  on  either  side  of  the  uterus.     According 
to  Coe,  they  are  attached  to  the  anterior  folds  of  the  broad  liga- 
ments, and  project  through  the  posterior.     They  are  situated  below 
the  outer  extremities  of  the  tubes. 

They  present  for  consideration  two  borders,  an  anterior  and  pos- 


32  ESSENTIALS  OF  GYNECOLOGY. 

terior ;  two  surfaces,  a  superior  and  an  inferior  ;  and  two  extremi- 
ties, an  outer  and  an  inner. 

The  anterior  border  is  nearly  straight ;  the  posterior  is  convex. 

The  anterior  border  is  called  the  hilum,  and  serves  for  the  en- 
trance of  blood  vessels  and  nerves. 

The  superior  surface  is  nearly  flat ;  the  inferior  is  convex. 

The  outer  extremity  is  broad  and  convex ;  the  inner  is  narrow  and 
tapers  into  the  ovarian  ligament. 

An  ovaiy  averages  about  IJ  inches  in  length,  |  of  an  inch  in 
breadth  and  i  an  inch  in  thickness ;  it  weighs  about  87  grains. 

Give  the  minute  anatomy  of  the  ovary. 

The  ovary,  on  section,  is  seen  to  consist  of  a  medullary  and  cor- 
tical portion ;  the  former  being  more  vascular  and  of  a  softer  con- 
sistency than  the  latter.  The  microscope  shows  connective  tissue, 
numerous  Graafian  follicles  scattered  through  the  cortex,  blood  ves- 
sels, lymphatics,  nerves  and  unstriped  muscular  fibres. 

The  ovary  is  usually  regarded  as  covered  by  a  layer  of  short 
columnar  epithelium,  "  germinal  epithelium,"  from  which  the  primi- 
tive ova  are  supposed  to  spring.  (Tait,  on  the  other  hand,  regards 
the  ovary  as  entirely  covered  by  peritoneum.) 

The  layer  of  ' '  germinal  epithelium  ' '  rests  on  a  thin,  dense  mus- 
culo-fibrous  layer,  called  the  tunica  albuginea. 

The  Grraafian  follicles  are  small  vesicular  bodies,  more  numerous 
and  smaller  in  the  superficial  zone  of  the  cortex  than  in  the  deeper, 
with  the  exception  of  a  few  which  have  matured  and  approached 
the  surface  of  the  ovary. 

Foulis  estimates  that  at  birth  each  human  ovary  contains  not  less 
than  30,000  Graafian  fohicles  (Playfair). 

Give  the  structure  of  a  Graafian  follicle. 

On  examining  a  Graafian  follicle  from  without  inward,  we  find 
the  following  structures  (Fig.  3) : — 

The  tunica  fibrosa,  which  is  highly  vascular ;  within  this  the 
tunica  propna,  of  more  condensed  connective  tissue  ;  within  this  is 
the  membrana  granulosa,  a  layer  of  columnar  epithelium  which 
encloses  the  liquor  follicuU;  at  one  side  there  is  a  cellular  eminence 
called  the  discus  proligerus,  which  encloses  the  ovum.  The  outer 
covering  of  the  ovum  is  the  vitelline  membrane,  or  zona  pellucida, 


OVARIES. 


surrounding  the  viteUns  or  yelk.  At  one  point  of  the  latter  is  seen 
the  germmal  vesicle,  and  within  this  the  germinal  spot.  A  Grraafian 
folhcle  measures  from  xw  to  ^  inch  in  diameter  ;  a  germinal  spot 


not  over 


inch. 


Give  the  arterial  and  venous  supply  of  the  ovaries. 

The  ovaries  are  supplied  by  the  ovarian  arteries,  which  arise 
directly  from  the  aorta. 

The  veins  of  the  ovary  emerge  at  the  hilum  and  enter  the  collec- 
tion of  veins  called  the  ' '  bulb  of  the  ovary. ' '  This  communicates 
with  the  veins  from  the  Fallopian  tube  and  upper  portion  of  the 

Fig.  3, 


Diagrammatic  Section  of  Graafian  Follicle. 
1.  Ovum.      2.  Membrana  granulosa.     -S.    External  membrane  of  Graafian  follicle. 
4.  Its  vessels.    5.  Ovarian  stroma.    6.   Cavity  of  Graafian  follicle.    7.  External 
covering  of  ovary. 

uterus,  forming  a  collection  called  the  pampiniform  or  ovarian 
plexus  ;  from  this  springs  the  ovarian  vein,  which,  on  the  right  side, 
terminates  in  the  inferior  vena  cava,  on  the  left  side,  in  the  left 
renal  vein.  The  left  ovarian  vein  has  no  valve  at  its  termination. 
Some  apply  the  term  pampiniform  plexus  to  all  the  veins  in  the 
broad  ligament. 

Give  the  lymphatics  and  nerve  supply  of  the  ovary. 

The  lymphatics  join  with  those  from  the  tube  and  upper  portion 
of  the  uterus  and  terminate  in  the  lumbar  glands.     The  nerve  sup- 
ply is  from  che  inferior  hypogastric  plexus. 
3 


34  ESSENTIALS  OF  GYNECOLOGY. 

What  is  the  position  of  the  long  axis  of  the  ovary? 

This  question  has  been  much  discussed.  The  long  axis  of  the 
ovary  may  be  regarded  as  lying  a  little  obhquely  to  the  transverse 
axis  of  the  pelvis,  and  with  a  direction  slightly  backward.  His 
describes  the  long  axis  as  vertical,  but  this  does  not  coincide  with 
the  results  of  autopsies  where  the  pelvic  contents  have  been  normai. 

Parovarium. 

Describe  it. 

The  parovarium,  which  is  the  remains  of  the  Wolffian  body,  con- 
sists of  a  series  of  tubes  situated  between  the  folds  of  the  broad 
hgament,  on  either  side  of  the  uterus,  and  lying  between  the  am- 
pulla of  the  tube  and  the  hilum  of  the  ovary. 

One  of  the  tubes  is  horizontal  and  rans  toward  the  uterus  ;  the 
others  are  nearly  vertical,  converging  toward  the  hUum  ;  they  vary 
greatly  in  number,  in  fact,  from  6  to  30. 

The  outer  6-10  have  a  well-marked  lumen  and  are  lined  with 
cihated  epithehum ;  those  internal  to  these  are  merely  fine  fibrous 
cords. 

The  horizontal  tube  running  toward  the  uterus  is  called  the  duct 
of  Grartner.  The  parovarium  is  of  pathological  importance,  as  occa- 
sionally the  seat  of  cysts. 

What  in  the  male  corresponds  to  the  parovarium  in  the 
female  ? 

The  epididymis. 

Urinary  Tract. 

Describe  the  urethra. 

The  female  urethra  is  a  musculo-membranous  canal  about  If 
inches  in  length,  imbedded  in  the  anterior  vaginal  wall,  and  extend- 
ing from  the  vestibule  to  the  neck  of  the  bladder  ;  it  mns  upward 
and  backward,  ' '  parahel  with  the  plane  of  the  pelvic  brim. ' ' 

It  consists  of  three  coats  •,.  the  outer  two  being  muscular,  the 
inner,  mucous  membrane. 

Of  the  muscular  coats,  the  outer  is  circular,  the  inner  longitudi- 
nal. The  mucous  membrane  in  the  lower  portion  of  the  canal  is 
covered  with  squamous  epithelium,  while  higher  up  the  epithelium 
is  transitional,  Hke  that  of  the  bladder. 


BLADDER.  35 

The  meatus  urinarius,  the  outer  extremity  of  the  urethra,  is  situ- 
ated in  the  median  line  at  the  base  of  the  vestibule. 

Describe  Skene's  tubules. 

Just  within  the  meatus,  on  each  side,  are  the  openings  of  Skene's 
tubules,  which  he  describes  as  lying  near  the  floor  of  the  urethra, 
just  beneath  the  mucous  membrane,  and  extending  parallel  to  the 
canal  about  three -fourths  of  an  inch.     Their  function  is  unknown. 

Bladder. 

Describe  it. 

The  bladder  is  a  hollow  musculo-membranous  organ,  situated  in 
the  pelvis  ' '  between  the  symphysis  pubis  in  front  and  the  vagina 
and  uterus  behind. ' ' 

The  bladder  presents  for  consideration  a  body,  a  base  or  fandus, 
and  a  neck.  The  body  is  all  that  portion  above  the  lines  joining  the 
ureteric  openings  and  the  centre  of  the  symphysis  pubis. 

All  below  these  lines  is  the  base  or  fundus.  The  portion  of  the 
fundus  between  the  urethral  and  ureteric  orifices  is  the  trigone. 

The  constricted  portion  continuous  with  the  urethra  is  the  neck. 

The  wall  of  the  bladder  consists  of  three  coats  :  a  peritoneal,  a 
muscular  and  a  mucous. 

The  peritoneal  coat  is  found  only  on  the  summit  of  the  bladder 
and  on  the  upper  part  of  the  posterior  surface.  The  muscular  coat 
consists  of  two  layers  :  an  outer  longitudinal  and  an  inner  circular  ; 
the  latter  being  most  marked  around  the  urethral  orifice. 

The  mucous  membrane  consists  of  several  layers  of  transitional 
epithelium  resting  on  a  membrana  propria  ;  the  superficial  cells  are 
squamous. 

The  mucous  membrane  is  thrown  into  numerous  folds,  except  at 
the  trigone,  where  it  is  more  closely  connected  with  the  underlying 
tissue. 

The  mucous  membrane  is  supported  by  a  submucous  layer  of  fibrous 
and  elastic  tissue,  containing  blood  vessels,  lymphatics  and  nerves. 

What  is  the  arterial  supply  of  the  bladder  and  urethra  ? 

The  bladder  receives  its  arterial  supply  from  the  superior,  middle 
and  inferior  vesical,  and  from  branches  of  the  uterine  and  vaginal 
arteries. 


36  ESSENTIALS   OF  GYNECOLOGY. 

They  are  all  derived  from  the  anterior  division  of  the  internal 
iliac. 
The  urethra  is  supplied  by  branches  from  the  vaginal  arteries. 

What  is  the  venous  supply  of  the  bladder  and  urethra  ? 

' '  The  veins  form  a  complicated  plexus  round  the  neck,  sides  and 
base  of  the  bladder. ' '     (Grray. ) 

This  is  called  the  vesical  plexus  ;  it  lies  external  to  the  muscular 
coat  and  terminates  in  the  internal  iliac  vein. 

The  urethra  is  surrounded  by  a  venous  plexus  which  communi- 
cates with  the  vaginal  plexus. 

Give  the  lymphatic  and  nerve  supply  of  the  bladder  and 
urethra. 
The  lymphatics  of  the  bladder  and  urethra  empty  into  the  iliac 
glands.  Their  nerve  supply  is  derived  from  the  inferior  hypogas- 
tric plexuses  of  the  sympathetic  system,  and  from  the  3d  and  4th 
sacral  nerves  of  the  cerebro-spinal  system. 

What  are  the  principal  venous  plexuses  of  the  pelvis  ? 

The  vaginal  plexuses. 

The  vesical  plexus. 

The  hemorrhoidal  plexus. 

The  uterine  plexus. 

The  pampiniform,  or  ovarian  plexus. 

The  bulb  of  the  ovary. 

Describe  the  course  of  the  ureters  in  the  pelvis. 

The  ureters  cross  the  external  iliacs  just  beyond  the  bifurcation  of 
the  common  iliacs  ;  they  then  pass  downward  and  outward  along  the 
lateral  walls  of  the  pelvis,  enter  the  broad  ligaments  and  run  forward 
and  inward.  At  the  level  of  the  internal  os  they  are  crossed  by  the 
uterine  arteries  (see  Fig.  4),  and  are  there  situated  about  half  an  inch 
from  the  uterus.  They  pass  alongside  of  the  vagina  a  little  way, 
converge  still  more,  enter  the  vesico-vaginal  septum  and  pierce  the 
bladder  a  little  above  the  middle  of  the  anterior  vaginal  wall ;  they 
are  here  separated  two  inches  from  each  other  and  one-half  to  three- 
fourths  of  an  inch  from  the  cervix. 


tlECTUM. 


37 


Rectum. 

Describe. 

The  rectum  is  the  lower  extremity  of  the  large  intestine,  about  8 
inches  in  length,  extending  from  near  the  left  sacro-iliac  synchron- 
drosis  to  terminate  in  the  anus  between  the  coccyx  and  perineum. 

Fig.  4. 


Drawing  from  a  dissection  made  to  show  relations  of  ureters,  uterine  arteries, 
bladder,  etc.    {J.  Greig  Smith.) 
ur.,  ureter;  uLAr.,  uterine  artery;  om  ,  os  uteii  exposed  by  an  incision,  x,  made 
through  the  top  of  the  vagina  ;  bl.,  bladder,  the  walls  of  which  are  cut  down  to  the 
insertion  of  the  ureters  into  its  base,  Vag  ,  vagina. 

It  presents  three  curves  : — 

1.  Downward,  backward  and  inward  to  the  3d  sacral  vertebra. 

2.  Forward  to  the  apex:  of  the  perineum. 

3.  Backward  to  the  anus. 

The  rectum  is  invested  by  peritoneum  at  its  upper  part. 


38  ESSENTIALS   OP  GYNECOLOGY. 

It  consists  of  a  mucous  and  a  submucous  layer  and  two  muscular 
layers — a  longitudinal  and  a  circular,  tlie  former  being  external. 

The  mucous  membrane  is  covered  with  columnar  epithelium  and 
contains  numerous  follicles  of  Lieberkiihn. 

At  its  lower  j^ortion  the  mucous  membrane  is  thrown  into  perpen- 
dicular folds  called  columns  of  Morgagni ;  the  depressions  between 
them  being  called  the  sinuses  of  Morgagni. 

There  are  three  oblique  folds  of  importance,  including  not 
only  the  mucous  and  submucous  layers,  but  part  of  the  muscular 
coat. 

One  projects  from  the  anterior  wall  1|  inches  from  the  anus. 

Another  is  on  the  right  side  near  the  sacral  promontory,  and  a 
third  is  situated  midway  between  the  two,  on  the  left  side. 

The  external  orifice  is  guarded  by  the  sphincter  ani  muscle  which 
surrounds  the  canal,  and  is  inserted  into  the  coccyx  behind  and  the 
perineum  in  front. 

Give  the  vascular  and  nerve  supply  of  the  rectum. 

The  arterial  supply  of  the  rectum  is  from  the  superior,  middle 
and  inferior  hemorrhoidal  arteries.  The  veins  form  a  plexus  beneath 
the  mucous  membrane  which  communicates  with  another  surround- 
ing the  exterior  of  the  canal ;  from  this  spring  veins  corresponding 
to  and  accompanying  the  arteries. 

The  superior  hemorrhoidal  vein  empties  into  the  inferior  mesen- 
teric of  the  portal  system. 

The  middle  and  inferior  hemorrhoidal  empty  into  the  internal 
iliac  of  the  general  venous  system. 

The  lymphatics  terminate  in  the  sacral  glands. 

The  nerves  are  derived  from  the  hypogastric  and  sacral  plexuses. 

Give  the  relations  of  the  rectum. 

At  its  upper  portion  the  rectum  is  surrounded  by  peritoneum  and 
lies  in  direct  relation  anteriorly  with  the  cul-de-sac  of  Douglas. 

At  about  3  inches  fi'om  the  anus  the  peritoneum  leaves  the  rectum, 
which  then  lies  loosely  attached  to  the  posterior  wall  of  the  vagina 
for  IJ  inches. 

The  remainder  is  separated  from  the  vagina  by  the  perineal  body. 

Posteriorly,  the  rectum  is  connected  at  its  upper  part  by  the  meso- 


PELVIC  FLOOR.  39 

rectum  to  the  sacrum ;   at  its  lower  part  hy  fibrous  tissue  to  the 
sacrum  and  coccyx. 

On  each  side  it  receives  the  insertion  of  the  levatores  ani  and  Ls 
surrounded  below  by  the  sphincter  ani. 


Pelvic  Floor. 

Describe  the  segments  of  the  pelvic  floor. 

According  to  Dr.  Hait,  the  pelvic  floor  consists  of  two  segments  : 
the  pubic  and  sacral ;  the  jnibic  consisting  of  the  bladder,  urethra, 
bladder  peritoneum  and  the  anterior  vaginal  wall ;  the  sacral  com- 
prising the  rectum,  perineal  body  and  posterior  vaginal  wall. 

According  to  the  same  authoiity,  also,  the  pubic  segment  is  made 
up  of  loose  tissue,  loosely  attached  to  the  pubes,  and  is  drawn  up 
during  labor  ;  the  sacral  segment  is  made  up  of  dense  tissue,  closely 
attached  to  sacrum  and  coccyx,  and  is  driven  down  during  labor. 

Describe  the  muscles  and  fascia  of  the  pelvic  floor,  as  dis- 
sected from  above. 

On  examining  the  pelvic  floor  from  abo  .e,  we  find  the  pelvic  fascia 
attached  laterally  to  the  brim  of  the  pelvis,  to  the  spine  of  the 
ischium  behind,  to  the  lower  portion  of  the  symphysis  pubis  in 
front,  and  to  a  tendinous  band — "white  line  " — joining  the  two  latter 
points.  Behind  the  spine  of  the  ischium  the  pelvic  fascia  is  con- 
tinuous with  a  thin  layer  covering  the  pyriformis  muscle.  At  the 
"white  line"  the  pelvic  fascia  divides  into  the  recto-vesical  fascia, 
which  covers  the  upper  surface  of  the  levator  ani  muscles,  and  the 
obturator  fascia,  covering  the  obturator  muscles.  The  recto-vesical 
fascia  arising  from  the  ' '  white  line  ' '  extends  downward  and  inward, 
and  unites  in  the  median  line  with  its  fellow  of  the  opposite  side. 
This  forms  a  fascial  diaphragm  which  is  perforated  by  the  rectum 
and  vagina,  to  each  of  which  it  is  firmly  attached  and  famishes  a 
sheath  from  that  point  downward.  The  bladder  and  rectum  also 
receive  ligaments  from  this  fascia. 

On  removing  this  fascial  diaphragm,  we  meet  with  a  muscular 
diaphragm  formed  by  the  levator  ani  and  coccygeus  muscle  of  each 
side  meeting  in  the  median  line. 


40  ESSENTIALS   OF  GYNECOLOGY. 

The  coccygei  arise  from  the  ischial  spines,  and  are  attached  to  the 
sides  of  the  lower  segment  of  the  sacrum  and  to  the  sides  and  ante- 
rior surface  of  the  coccyx. 

The  levatores  ani  arise  from  the  posterior  aspect  of  the  pubes, 
from  the  spine  of  the  ischium  and  from  the  "white  hne  "  of  the 
pelvic  fascia  connecting  these  points.  They  extend  downward  and 
inward  and  are  attached  to  the  vagina,  the  rectum,  to  each  other 
and  to  the  tip  of  the  coccyx.  This  muscular  diaphragm  surrounds 
both  vagina  and  rectum. 

The  under  surface  of  this  muscular  diaphragm  is  covered  by  a  thin 
layer  of  fascia  which  is  attached  on  each  side  to  the  obturator  fascia. 
On  removing  the  muscular  diaphragm  with  its  upper  and  lower 
fascia,  there  remains,  filling  the  pelvic  outlet,  the  perineal  body,  the 
muscles  of  the  perineum  and  the  ischio-rectal  fossa. 


Perineal  Body. 

Describe. 

The  perineal  body  is  a  mass  of  muscular,  fibrous  and  adipose 
tissue,  somewhat  pyramidal  in  shape,  lying  between  the  lower  ends 
of  the  vagina  and  rectum  ;  it  measures  H  inches  in  height,  Ij 
inches  in  breadth  and  |  inch  antero-posteriorly.  Its  base  is  covered 
by  skin  which  is  sometimes  wrongly  spoken  of  as  "  the  perineum, ' ' 
which  should  always  refer  to  the  perineal  body. 

The  muscles  which  are  attached  to  the  perineal  body  are  the 
bulbo-cavernosi,  transversi  perinei,  sphincter  and  levatores  ani. 

Give  the  vascular  and  nerve  supply  of  the  perineal  body. 

The  arterial  supply  of  the  perineal  body  is  from   the  internal 
pudics. 
The  veins  terminate  in  the  pudic  veins. 
The  lymphatics  end  in  the  inguinal  glands. 
The  nerve  supply  is  from  the  pudic  nerve. 

What  are  the  functions  of  the  perineal  body  ? 

1.  To  prevent  vaginal  rectocele. 

2.  To  help  form  a  compact  pelvic  floor. 

3.  To  serve  as  a  fixed  point  for  muscular  attachment. 


ISCHIO-RECTAL  FOSSA.  4l 

Muscles  of  the  Perineum. 

Name  and  describe  them. 

On  each  side  of  the  vaginal  orifice  we  find  three  muscles  :  bulbo- 
cavernosus,  ischio-cavernosus  or  erector  clitoridis,  and  the  traos- 
versus  perinei. 

The  bulbo-cavernosus  arises  from  the  perineal  body  on  each  side 
of  the  vagina,  with  its  fellow  encircles  the  vaginal  bulbs  and  vesti- 
bule, and  divides  into  three  slips  ;  one  going  to  the  posterior  surface  of 
the  bulb,  another  to  the  under  surface  of  the  corpus  cavernosum  of 
the  clitoris,  and  the  third  to  the  mucous  membrane  of  the  vestibule. 

The  bulbo-cavernosi  compress  the  bulbs  of  the  vagina. 

The  transversus  perinei  arises  from  the  ramus  of  the  ischium  and 
is  lost  in  the  perineal  body. 

The  ischio-cavernosus  or  erector  clitoridis,  arises  from  the  front  of 
the  tuberosity  of  the  ischium  and  is  inserted  into  the  cms  chtoridis. 

These  muscles  are  supplied  by  the  internal  pudic  artery  and  by 
branches  of  the  pudic  nerve. 

The  veins  enter  the  pudic  veins. 

The  lymphatics  terminate  in  the  inguinal  glands. 

Ischio-reetal  Fossa. 

Give  its  gross  anatomy. 

It  is  a  pyramidal-shaped  area,  largely  filled  with  fat,  situated  on 
either  side  of  the  rectum ;  the  sides  aie  formed  by  the  obturator 
internus  without  and  the  levator  ani  within  ;  the  base  by  the  trans- 
versus perinei  and  the  lower  edge  of  the  gluteus  maximus. 

Describe  the  fascia  covering  the  pelvic  floor  below. 

From  without  inward  we  find  the  supei-ficial  fascia  in  two  layers, 
the  external  being  continuous  with  the  general  supei'ficial  fascia  of 
the  body.  The  deep  layer  is  attached  to  the  border  of  the  pubic 
arch  in  front  and  laterally ;  posteriorly,  it  passes  around  the  trans- 
versus perinei  muscles  and  is  attached  to  the  base  of  the  anterior 
layer  of  the  triangular  ligament. 

Beneath  the  perineal  muscles  we  find  the  triangular  ligament,  con- 
sisting of  two  layers  of  fascia,  the  anterior  and  posterior,  filling  in 
the  pubic  arch. 


42  ESSENTIALS  OF  GYNAECOLOGY. 


Development  of  the  Pelvic  Organs. 

Describe  briefly. 

In  the  latter  part  of  tlie  first  month  there  appear  in  the  foetus, 
on  either  side  of  the  primitive  vertebrae,  the  Wolffian  bodies,  which 
play  the  part  of  temporary  kidneys.  They  soon  wither,  and  by  the 
end  of  the  3d  month  have  largely  disappeared,  but  their  remains  per- 
sist, in  the  female,  in  the  parovarium  and  Graertner's  duct.  At  the 
inner  side  of  the  Wolffian  bodies  there  appears  an  invagination  of 
Hae  germ  epithelium  ;  this  develops  into  the  duct  of  Mueller,  one 
for  each  Wolffian  body.  These  coalesce  below  to  form  the  uterus 
and  vagina. 

The  ovary  first  appears  as  a  white  ridge  on  the  inner  side  of  the 
Wolffian  body  ;  this  ridge  being  formed  of  connective  tissue  covered 
with  germ  epithelium  ;  from  the  former  is  developed  the  stroma  of 
the  ovary,  and  from  the  latter  are  formed  the  Grraafian  follicles  and 
ova. 

Until  the  latter  part  of  the  second  month  of  foetal  life  the  urinary, 
genital  and  intestinal  canals  open  into  a  common  vault — the  cloaca. 
At  about  the  6th-7th  week  this  common  opening  is  divided  into  the 
anal  opening  posteriorly  and  the  uro-genital  anteriorly.  This  sepa- 
ration is  completed  by  the  formation  of  the  perineal  body  at  about 
the  tenth  week. 

The  uro-genital  canal  is  later  divided  into  the  ui'ethra  anteriorly 
and  the  vagina  posteriorly. 


Physical  Examination  of  the  Female  Pelvic 

Organs. 

What  are  the  methods  of  examination? 

I.  Non-instrumental.     II.  Instrumental. 
I.  Non-instrumental. 

a.  Inspection  of  external  genitals. 

h.  External  abdominal  examination. 

c.  Vaginal  examination. 

d.  Bimanual  examination,  with  its  modifications. 

e.  Rectal  examination. 


VAGINAL  EXAMINATION.  43 

What  should  you  notice  on  inspection  of  the  external  gen- 
itals ? 

1 .  Notice  whether  or  not  the  vulva  is  the  seat  of  venereal  sores 
warts,  abscesses,  pedicuH,  etc. 

2.  Separate  labia  and  notice  condition  of  hymen  and  perineum, 
whether  intact  or  lacerated  ;  the  shape  of  hymen  if  intact.  If  peri- 
neum lacerated,  notice  whether  through  the  sphincter  ani  or  not ; 
notice,  also,  condition  of  urethra. 

3.  Tell  patient  to  strain,  and  with  labia  still  separated,  notice 
whether  anterior  or  posterior  vaginal  walls  prolapse  or  not,  thus 
forming  cystocele  or  rectocele. 

4.  During  this  inspection  it  is  well  to  pass  the  thumb  and  fore- 
finger along  each  labium  majus  to  ascertain  whether  the  vulvo- 
vaginal glands  or  their  ducts  are  enlarged  or  not. 

What  are  the  principal  elements  in  a  complete  external  ab- 
dominal examination  ? 

1.  Position  and  Preparation  of  patient. — Patient  should  be  on 
back  with  knees  drawn  up  'j  the  abdomen  should  be  uncovered  as 
low  down  as  the  pubes  ;  the  latter  not  being  exposed  ;  bladder  and 
rectum  should  be  empty. 

2.  Inspection. — Observe  the  form  and  color ;  notice  whether 
irregularities  in  form  are  present  or  not. 

3.  Palpation. — Use  both  hands  ;  they  should  be  warm  ;  use  the 
palms  and  palmar  surface  of  fingers  rather  than  their  tips  ;  employ 
very  little  force.  If  a  tumor  is  present,  notice  whether  it  is  solid  or 
fluctuating,  whether  fixed  or  mobile  ;  if  possible,  determine  whether 
or  not  it  is  attached  to  one  of  the  pelvic  organs. 

Notice  whether  it  pulsates  or  is  the  seat  of  intermittent  contrac- 
tions. 
Palpate  inguinal  regions  for  enlarged  glands  or  hemiae. 

4.  Percussion. — Patient  should  be  first  percussed  in  usual  manner 
while  lying  on  back  and  then  when  turned  on  either  side. 

Vaginal  Examination. 

Describe  the  method  of  performing  it. 

Have  the  patient  on  back  ;  knees  drawn  up  ;  if  a  married  woman, 
employ  two  fingers,  if  unmarried,  use  one. 


44  ESSENTIALS   OF   GYNECOLOGY. 

Have  the  examining  finger  or  fingers  well  lubricated  and  folded 
into  the  palm  until  you  approach  the  vulva  ;  then  let  them  sweep 
over  the  perineum  and  fourchette  between  the  labia  till  they  enter 
the  vagina,  orifice.  Do  not  pass  from  above  downward  over  the 
clitoris.  After  entering  the  vagina  pass  the  finger  or  fingers  back- 
ward toward  the  hollow  of  the  sacnim. 

What  are  the  contraindications  to  a  vaginal  examination  ? 

A  vaginal  examination  should  not  be  made  in  an  unmarried 
woman  unless  there  are  strong  reasons  for  suspecting  trouble  with 
the  pelvic  organs,  and  then  only  in  the  presence  of  a  relative  or 
female  friend. 

It  should  not  be  made  during  a  normal  menstruation. 

"What  is  the  value  of  a  vaginal  examination  per  se  ? 

The  value  of  a  vaginal  examination  by  itself  is  comparatively 
small ;  and  it  is  rarely  employed  save  as  a  part  of  a  bimanual 
examination. 

One  can,  however,  determine  the  following  jDoints  by  a  vaginal 
examination,  and  they  should  be  carefully  noted  : — 

The  condition  of  perineum  and  vaginal  orifice. 
Presence  or  absence  of  Painful  Spots  ; 

Spasm  ; 

Enlargement  of  vulvo-vaginal  glands  ;  etc. 
Condition  of  vaginal  walls : — 

Heat ; 

Moisture ; 
Presence  or  absence  of 

Kugae ; 

New  growths ; 

Fistulas ;  etc. 
Projections  of  vaginal  walls  fi'om 

FaBces  in  rectum ; 

Inflammatorj^  deposits ; 

Tumors  in  the  peritoneal  pouches. 
Condition  of  cervix  : — 


Position  ; 

Density ; 

Shape ; 

Mobility ; 

Size ; 

Tjacerated  or  not 

BIMANUAL  EXAMINATION.  45 

Condition  of  os  : — 

Size  ; . 

Shape ; 

Projections  through  it. 

Bimanual  Examination. 

What  is  the  method  of  performing  it  ? 

The  position  of  the  patient  and  the  method  of  introducing  fingers 
are  the  same  as  for  the  vaginal  examination  just  described.  As 
regards  which  hand  shall  be  used  internally,  the  right  is  usually 
employed  first ;  but  to  make  a  complete  bimanual,  it  is  best  to 
employ  internally  the  right  hand  for  the  right  side  of  the  pelvis, 
and  the  left  hand  for  the  left ;  in  this  way  the  palmar  surfaces  of 
the  internal  and  external  fingers  are  approximated,  and  any  depart- 
ure from  the  normal,  on  either  side,  is  better  mapped  out  than 
when  the  right  hand  alone  is  used  for  the  internal  examination. 

Describe  the  use  of  the  external  hand  in  the  bimanual. 

The  ulnar  surface  of  the  external  hand  should  be  used  rather  than 
the  palm ;  it  should  be  applied  to  the  abdomen  a  little  above  the 
pubes  and  steadily  depressed  toward  the  opposing  fingers  within  the 
vagina,  while  the  patient  relaxes  her  abdominal  muscles  and  breathes 
quietly,  with  mouth  open. 

Describe  the  use  of  the  internal  examining*  fingers  in  the 
bimanual. 

While  the  ring  and  little  fingers  are  strongly  flexed  into  the  palm 
and  the  thumb  lies  on  the  pubes  or  between  the  thighs,  place  the 
middle  examining  finger  on  the  cervix  and  the  index  in  the  anterior 
fornix  and  raise  the  uterus  toward  the  external  hand.  The  first 
step  for  the  student  in  acquiring  skill  in  the  bimanual  is  to  feel, 
through  the  abdominal  wall,  a  body  which  transmits  motion  from 
the  external  hand  to  the  finger  on  the  cervix.  This,  in  a  nomial 
case,  is  the  fundus  of  the  uterus  ;  future  examinations  will  enable 
one  to  map  out  more  and  more  the  shape  of  the  fundus. 

What  is  a  good  order  to  follow  in  making  a  bimanual  exam- 
ination  ? 
1.  Determine  the  position  of  the  uterus  by  attempting  to  approxi- 


46  ESSENTIALS  OF  GYNECOLOGY. 

mate  external  and  internal  fingers  ;  the  internal  being  placed  first  on 
cervix,  then  in  anterior  fornix  and  then  in  posterior ;  the  external 
hand  exerting  counter  i)ressure. 

2.  Determine  condition  of  tubes,  ovaries  and  parametria ;  using 
right  hand  internally  for  right  side  of  the  pelvis  and  left  for  left. 

Should  you  normally  feel  a  hard  body  in  any  of  the  four  for- 
nices  of  the  vagina  ?  If  so,  which  one,  and  what  is  it? 

Yes,  in  the  anterior  fornix  ;  the  body  of  the  uterus. 

Should  you  normally  feel  a  hard  body  in  the  posterior  or 
either  of  the  lateral  fornices  ? 

No. 

What  mass  might  you  feel  in  the  anterior  fornix  ? 

1.  A  fibroid  on  anterior  wall  of  the  uterus. 

2.  Inflammatory  or  blood  effusions,  rarely. 

What  mass  might  you  feel  in  either  of  the  lateral  fornices  ? 

Inflammatory  deposit  from  cellulitis  or  peritonitis. 
Blood  effusion. 
Enlarged  tube  or  ovary. 
Body  of  uterus  latero-flexed. 
Lateral  fibroid. 

What  mass  might  you  feel  in  posterior  fornix  ? 

Displaced  fundus. 

Faeces  in  rectum. 

Fibroid  on  wall  of  uterus. 

Peritonitic  or  cellulitic  deposit. 

Haematocele. 

Displaced  ovary. 

Tumor. 

Rectal  Examination. 

What  are  the  methods  ? 

1.  Simple  rectal. 

2.  Abdomino-rectal. 

3.  Simon's  method. 

What  are  the  preliminaries  to  any  rectal  examination  ? 
Have  bowels  empty. 
Tell  patient  what  you  are  to  do. 


INSTRUMENTS —SPECULA.  47 

Have  soap  under  finger-nail. 
Lubricate  finger. 

How  would  you  perform  the  simple  rectal  examination  ? 

Having  observed  the  preceding  preliminaries,  pass  tbe  finger  for- 
ward, noting  the  presence  or  absence  of  hemorrboids,  fissures,  polypi, 
stricture,  etc. ,  till  tbe  cervix  is  felt,  tben  pass  along  posterior  wall 
of  tbe  uterus. 

How  would  you  perform  the  abdomino-rectal  examination  ? 

Passing  tbe  right  index  finger  into  the  rectum  as  just  described, 
use  tbe  left  band  externally,  placed  on  tbe  abdomen  as  in  tbe  Drdi- 
nary  bimanual. 

What  is  Simon's  method  ? 

This  consists  in  passing  tbe  whole  band,  shaped  like  a  cone, 
gradually  through  tbe  anus  into  tbe  rectum. 

What  is  the  value  of  the  different  methods  of  rectal  exami- 
nation ? 

Both  the  simple  rectal  and  abdomino-rectal  are  of  especial  value 
in  virgins,  where  the  ordinary  bimanual  is  painful  or  objected  to. 

By  means  of  a  volsella  forceps  you  may  draw  down  tbe  cervix,  and 
tben,  with  finger  in  tbe  rectum,  palpate  tbe  posterior .  surface  of 
uterus,  tubes  and  ovaries. 

The  above  methods  of  rectal  examination  are  of  value  in  any  case 
where  you  wish  to  reach  higher  than  is  possible  with  tbe  ordinary 
bimanual. 

Advantage  is  sometimes  gained  by  making  tbe  rectal  examination 
with  patient  in  Sims'  position. 

Simon's  method  is  dangerous  and  seldom  justifiable. 


INSTRUMENTS. 

Specula. 

What  are  the  three  classes  of  specula  in  most  common  use  ? 

1.  The  Spatular. 

2.  The  Cylindrical. 

3.  Tbe  Bivalve. 


48 


ESSENTIALS   OF   GYNECOLOGY. 


Give  one  of  the  best  examples  of  the  spatular  variety; 
describe  it. 

The  Sims  speculum  (see  Fig.  5)  is  the  best  example  of  this  class ; 
it  consists  of  two  blades  united  by  a  handle  at  right  angles  to  them, 

the  blades  being  convex  on 

the  sides  facing  each  other, 

concave    on    the    opposite. 

Many  modifications  are  made 

by  which  the  length  of  blade, 

angle  at  which  it  joins  the 

shaft,   and   weight    of  the 

instrument    are    al- 

One  blade  of   the 

speculum    is   usually 

shorter  and    smaller 


Sims'  Speculum. 


whole 

tered. 

Sims 

made 

than  the  other. 


"What  are  the  advantages  of  Sims'  speculum  ? 

It  does  not  distort  cervix. 

It  gives  a  good  view  of  all  but  the  posterior  vaginal  wall,  and  is 
the  best  suited  for  operations  on  cervix  and  anterior  vaginal  wall. 

What  are  the  disadvantages  of  Sims'  speculum  ? 

It  requires  an  assistant  with  some  training  to  hold  it. 
It  requires,  in  most  cases,  the  use  of  a  vaginal  depressor,  thus 
employing  one  hand. 

"What  is  the  proper  position  of  the  patient  for  the  use  of  Sims' 
speculum  ? 

A  patient  in  the  so-called  "  Sims  position  "  should  lie  on  her  left 
side,  with  left  buttock  on  the  left  corner  of  the  table,  as  you  :fece  it ; 
the  head  being  at  the  right  corner  of  the  head  of  the  table,  the  left 
arm  behind  the  j^atient ;  the  right  arm  should  he  over  the  right 
edge  of  the  table,  the  right  shoulder  being  kept  as  near  the  table  as 
possible.  The  knees  should  be  drawn  up,  the  right  a  little  above 
the  left. 

How  would  you  introduce  a  Sims  speculum  ? 

Having  placed  the  patient  in  the  correct  Sims  position,  select  the 
blade  you  are  to  use ;  warm  and  lubricate  the  convex  side  of  it ; 


INSTRUMENTS— SPECULA. 

Fig.  6. 


49 


take  tlie  speculum  in  the  riglit  hand  with  the  index  finger  lying  in 
the  concavity  of  the  blade,  and  introduce  finger  and  blade  together. 
The  breadth  of  the  blade  should  be  in  line  with  the  labia  until  it 
has  entered  the  vaginal  oiifice  ;  it  should  then  be  rotated  till  the 
convexity  lies  in  apposition  with  the  posterior  vaginal  wall,  which  it 
should  hug  closely  till  the  jwsterior  fornix  is  reached  and  the  index 
finger  detects  the  cei-vix  in  front  of  it ;  the  speculum  is  then  given 
to  an  assistant  to  hold.  Some  introduce  the  finger  fii'st  and  pas? 
the  blade  along  it. 

Fig.  7. 


Simon'.s  Speculum. 


How  would  you  hold  a  Sims  speculum  ? 

There  are  two  methods  in  common  use  : — • 

{(t)  One  is  to  grasp  the  outside  blade  with  the  right  hand,  the 

angle  between  blade  and  handle  fitting  over  index  finger,  as  seen  in 

Fig.  0  ;  the  thumb  lying  in  the  concavity  of  the  blade  over  the 

angle. 

4 


50 


ESSENTIALS   OF   GYNECOLOGY. 


The  right  buttock  should  be  raised  with  the  left  hand. 

{h)  The  other  method  is  to  grasp  the  handle  of  the  speculum  with 
the  right  hand,  having  the  convexity  of  the  outside  blade  rest  in 
the  hollow  between  the  thumb  and  index  finger. 

The  right  buttock  being  raised  as  in  the  other  method. 

What  is  a  Simon's  speculum  ? 

A  very  valuable  speculum  of  the  spatular  variety  is  called  Simon's 
(see  Fig.  7.)  It  consists  of  a  common  handle  into  which  fit,  at 
right  angles  to  it,  blades  of  different  sizes  and  shapes.  It  is  of 
especial  value  with  the  patient  in  the  dorsal  position,  for  retracting 
the  perineum  in  curetting  the  uterus  or  operating  upon  the  cervix. 


Fig.  8 


Fergussou's  Speculum. 


What  is  one  of  the  best  examples  of  a  cylindrical  speculum  ? 
Describe  it. 

The  cylindrical  speculum  of  Fergusson  (see  Fig.  8)  is  probably  the 
best  of  its  class  ;  it  is  a  cylinder  of  glass  or  hard  rubber,  with  one 
extremity  beveled  and  the  other  trumpet-shaped. 

The  glass  ones  usually  present  a  mirrored  surface  from  within. 

The  beveled  extremity  is  the  one  first  introduced. 

What  are  the  merits  of  the  Fergusson  speculum  ? 

It  is  of  very  limited  use  ;  it  may  be  employed  for  inspecting  the 
cervix  or  making  applications  to  it.  It  is  useless  for  operations  on 
the  cervix  ;  it  is  only  partially  self-retaining,  and  its  introduction  in 
nulliparae  is  painful. 

How  would  you  introduce  a  Fergusson  speculum  ? 

In  this  country  the  Fergusson  speculum  is  usually  employed  with 
the  patient  in  the  dorsal  position. 

Separate  the  labia  with  the  fingers  of  the  left  hand  ;  holding  the 
tnimpet-shaped  extremity  with  the  right  hand,  introduce  the 
beveled  extremity  into  the  vaginal  orifice  having  the  shorter  side 


INSTRU3IENTS — SPECULA. 


51 


anterior  ;  depress  well  the  perineum,  directing  the  speculum  toward 
the  hollow  of  the  sacrum  ;  by  slight  vertical,  horizontal  or  rotatory 
motion  of  the  speculum  while  looking  into  it,  the  cervix  is  now 
usually  brought  into  view  without  difficulty.  It  is  occasionally 
convenient  to  draw  the  cervix  more  fully  into  view  by  means  of  a 
tenaculum. 

Some  gynsecologists  use  the  Fergusson  speculum  with  the  patient 
in  Sims'  position. 

Fig.  9. 


A^^^ 


Brewer's  Speculum. 


What  is  one  of  the  best  examples  of  a  bivalve  speculum  ? 
Describe  it. 

The  Brewer  bivalve  (see  Fig.  9)  is  probably  the  best  speculum 
of  its  class ;  it  consists  of  two  blades,  the  outer  extremities  being 
trumpet-shaped  where  they  are  jointed  ;  the  anterior  blade  is  shorter 
than  the  posterior,  and  has  a  slot  in  its  outer  half,  to  avoid  pressure 
on  tlie  urethra  ;  this  also  facilitates  the  introduction  of  the  sound  or 
probe.  The  speculum  is  opened  by  approximating  the  handles  of 
the  blades  and  held  there  by  a  thumb-screw.  There  are  two  sizes 
of  Brewer's  speculum,  the  long  and  short. 

How  would  you  introduce  a  Brewer  speculum  ? 

Place  patient  in  dorsal  position  ;  pass  speculum  into  vaginal  orifice 
with  the  blades  lateral,  then  rotate  till  they  are  antero-posterior ; 
begin  to  open  blades  just  before  they  reach  the  cervix ;  when  com- 
pletely open,  hold  with  thumb-screw. 


52 


ESSENTIALS   OF   GYNECOLOGY. 


What  are  the  merits  of  Brewer's  speculum  ? 

For  inspection  of,  and  applications  to,  the  cervix,  it  is  very  valu- 
able ;  it  is  self-retaining,  thus  obviating  the  necessity  of  an  assistant. 

The  long  instrument  is  better  than  the  short,  as  with  it  the 
vaginal  walls  are  not  as  likely  to  obstruct  the  view  by  falling  in  be- 
yond the  blades,  and  at  the  same  time  it  accomplishes  all  that  the 
short  instrument  does. 

What  is  the  best  speculum  for  examination  of  the  interior  of 
the  bladder  ? 

The  simplest  and  best  speculum  for  direct  inspection  of  the  inte- 
of  the  bladder  is  that  devised  by  Dr.  Kelly,  of  Baltimore 


nor 


Fig.  9i. 


Kelly's  speculum  ready  for  introduction  (a) ;  6,  speculum  with  obturator  removed. 


(Fig.  9^).     It  is  a  tubular  siDcculum  with  obturator,  and  comes  in 
several  sizes. 

Describe  its  use. 

The  bladder  is  emptied ;  the  patient  is  placed  in  an  exaggerated 
lithotomy  position,  with  hips  elevated  8  to  16  inches  above  the 
table.  One  of  the  smaller  sized  specula  is  introduced,  and  then 
a  larger,  until  the  desired  size  is  reached.     The  obturator  is  then 


INSTRUMENTS — VOLSELLA. 


53 


withdrawn,  and  air  enters  and  distends  the  bladder.  The  residual 
urine  is  removed  by  pledgets  of  cotton  held  in  long  thumb-forceps ; 
light  is  thrown  into  the  bladder  by  means  of  a  forehead  mirror,  and 
by  turning  the  speculum  in  dijEFerent  directions  nearly  the  whole  of 
the  interior  of  the  bladder  may  be  inspected,  and  through  the  spec- 
ulum the  ureters  may  be  catheterized. 

For  a  thorough  examination  anaesthesia  is  desirable. 

Fig.  10.  What  are  the  disadvantages  of  Brewer's 

speculum  ? 

It  distorts  the  cervix,  obscures  the  anterior 
vaginal  wall,  and  cannot  be  used  for  operations 
on  the  cervix  or  vagina. 

Volsella. 

Describe  it. 

The  A^olsella,  or  vulsellum  forceps  (see  Fig.  10) 
consists  of  a  pair  of  hooks  with  scissor  handles 
and  joint ;  the  hooks  usually  consist  of  two  or 
more  teeth  ;  the  handles  fasten  with  a  catch. 

What  are  the  uses  of  the  Volsella  ? 

In  all  operations  on  the  cervix,  trachelor- 
rhaphy, dilatation,  etc. ,  the  volsella,  or  one  of 
its  substitutes,  is  almost  indispensable,  to  draw 
down  and  hold  the  cervix. 

For  applications  to,  or  operations  on,  the 
interior  of  the  body  of  the  uterus,  the  volsella 
is  also  of  great  value. 

The  use  of  the  volsella  to  draw  down  the 
cervix,  in  connection  with  the  finger  in  the  rectum,  in  the  combined 
rectal  examination,  is  of  great  importance. 

How  would  you  introduce  and  apply  the  Volsella? 

The  position  for  most  operations  on  the  ceiTix  is  the  Sims  position, 
consequently  the  volsella  is  most  often  used  in  this  position.  It  may 
be  introduced  either  without  or  with  the  use  of  the  speculum  ;  if 
without  the  speculum,  the  first  two  fingers  of  the  right  hand  are 
introduced  till  the  anterior  lip  of  the  cervix  is  felt ;  the  volsella  is 


The  Volsella. 


54  ESSENTIALS   OP  GYN^COLOGl. 

then  passed  along  them  and  applied  to  the  anterior  lip,  which  is 
then  drawn  down. 

The  better  way  is  usually  to  employ  Sims'  speculum  and  apply  the 
volsella  directly  to  the  anterior  lip  by  sight. 

The  volsella  is  occasionally  employed  with  patient  in  the  dorsal 
position,  the  instrument  being  introduced  either  by  touch,  or  sight 
aided  by  a  speculum. 

What  could  you  substitute  for  a  Volsella  ? 

A  bullet  forceps  with  a  catch  makes  a  very  good  substitute  for  n 
volsella  and  is  getting  to  be  preferred  to  it,  as,  having  but  one  pair 
of  teeth,  it  occupies  less  space  on  the  cervix. 

A  tenaculum,  such  as  Sims',  which  is  a  sharp  hook  on  a  long 
slender  shank,  is  often  of  great  use  in  holding  the  cervix  and  draw- 
ing it  in  any  direction,  and  can  sometimes  be  substituted  for  a  vol- 
sslla. 

Uterine  Sound. 

What  are  the  two  sounds  in  most  general  use  ?  their  descrip^ 
tion  and  merits  ? 
The  Sir  J.  Y.  Simpson's  sound  and  that  of  A.  R.  Simpson  are 
the  two  in  most  general  use. 

Fig.  11. 


Sir  J.  Y.  Simpson's  Sound. 


They  are  both  rods  of  copper,  nickel-plated,  and  so  pliable  that 
they  can  easily  be  bent  with  the  fingers. 

The  sound  of  Sir  J.  Y.  Simpson  (see  Fig.  11)  is  12  inches  long, 
with  a  notched  knob  2J  inches  from  the  end,  and  notches  at  3^,  4^, 
etc.,  up  to  8 J  inches, 

The  handle  is  roughened  on  the  side  of  the  concavity  of  the 
curve. 


INSTRUMENTS — UTERINE  SOUND. 


55 


The  sound  of  A.  R.  Simpson  (see  Fig.  12)  is  only  9  inches  long ; 
it  has  a  prominent  ring  at  2^  inches  and  two  rings  at  4 J  inches ; 
there  are  also  markings  at  3  J  and  5  J  inches.  This  sound  has  an 
advantage  over  the  preceding  in  that,  being  only  9  inches  long,  the 
handle,  which  is  broad,  can  rest  firmly  on  the  ball  of  the  little  finger 
even  when  the  tip  of  the  index  finger  is  on  the  2J  inch  ring,  thus 
giving  one  a  comjDlete  control  of  the  instrument  when  the  finger  is 
in  the  vagina  with  the  sound.     This  is  impossible  with  the  sound  of 

Fig.  12. 


A.  R.  Simpson's  Sound.    {Hart  and  Barbour.) 


Sir  J.  Y.  Simpson,  as  in  similar  circumstances  the  handle  is  far 
above  the  hand,  and  one  can  only  grasp  the  shank,  which  readily 
rotates.  The  pre-sence  of  the  double  ring  is  also  an  advantage  in  an 
enlarged  uterus. 

What  are  the  contraindications  to  the  use  of  the  sound  ? 
Patient  has  skipped  a  menstrual  period. 
Menstruation  present. 

Acute  inflammation  present  in  uterus  or  neighborhood. 
]\Ialignant  disease  of  uterus. 

What  are  the  preliminaries  to  the  use  of  the  sound  ? 

1.  Thoroughly  sterilize  the  sound. 

2.  Be  sure  that  the  patient  has  not  skipped  a  menstrual  period. 


56  ESSENTIALS   OF   GYNAECOLOGY. 

3.  Determine  position  of  uterus  by  a  careful  examination. 

4.  Curve  sound  to  the  curve  of  the  uterus. 

5.  Cleanse  the  vagina  with  an  antiseptic  solution.  This  is  of  im- 
portance to  avoid  carrying  septic  material  from  vagina  to  uterus  by 
the  sound.  For  this  reason  it  is  always  wiser  to  introduce  the  sound 
with  the  aid  of  a  speculum,  which  separates  the  vaginal  walls  and 
enables  j"0u  to  reach  the  os  directly. 

6.  Position  of  the  patient : — 

This  is  largely  a  matter  of  choice,  but  in  this  country  the  dorsal 
position  is  usually  selected,  and  it  has  the  advantage  that  in  this 
position  the  bimanual  may  be  easily  combined  with  the  use  of  the 
sound. 

How  would  you  introduce  the  sound  with  patient  in  the  dor- 
sal position  ? 

Havmg  mtroduced  a  speculum  and  thoroughly  cleansed  the 
vagina,  be  sure  your  sound  is  aseptic  and  then  pass  it  by  sight 
directly  into  the  os.  The  introduction  is  often  most  easijy  accom- 
plished if  the  uterine  body  lies  forward  by  starting  the  sound  with 
its  concavity  backward,  then,  when  the  point  is  engaged  in  the  cer- 
vical canal,  turning  the  sound,  not  hy  rotating  the  shank,  but  by 
making  the  handle  describe  a  semicircle  from  behind,  to  the  left 
and  forward ;  the  point  of  the  instrument  remaining  nearly  station- 
ary. By  depressing  the  handle  toward  the  perineum,  the  sound 
will  then  usually  pass  without  trouble.  If  the  point  catches  in  the 
crypts  of  the  cervix,  slight  motion  will  usually  disengage  it. 

What  variation  in  this  procedure  would  you  make  if  the 
fundus  lay  posteriorly? 

Having  introduced  the  sound  into  the  cervix  as  before,  with  con- 
cavity backward,  continue  the  introduction  without  the  semicircular 
motion  of  the  handle.- 

In  this  position  of  the  fundus  the  sound  is  sometimes  most  easily 
introduced  by  a  maneuver  similar  to  that  in  the  preceding  case  but 
in  the  opposite  direction,  viz. ,  starting  with  the  concavity  of  the 
sound  forward,  make  the  handle  describe  a  semicircle  from  before 
backward. 


INSTRUMENTS— UTERINE  SOUND.  57 

How  would  you  pass  the  sound  in  a  marked  case  of  ante- 
flexion ? 

If  the  uterus  is  anteflexecl,  the  introduction  of  the  sound  is  facih- 
tated  b}'  curving  the  sound  sharply,  and  drawing  down  and  steady- 
ing the  cervix  with  a  bullet  forceps. 

How  would  you  introduce  the  sound  with  patient  in  Sims' 
position  ? 

Here,  as  in  the  dorsal  position  of  the  patient,  the  introduction 
of  the  sound  should  be  j^receded  by  the  introduction  of  the  specu- 
lum and  the  cleansing  of  the  vagina  and  cervix  ;  the  sound  rendered 
aseptic  is  then  passed  by  sight  directly  into  the  os  without  being 
allowed  to  touch  the  vaginal  walls :  in  this  way  the  introduction  of 
sepsis  into  the  uterus  is  avoided.  The  further  introduction  of  the 
sound  may  be  continued  with  the  concavity  forward,  or  starting 
with  the  concavity  backward  the  semicircular  motion  of  the  handle 
from  behind  forward  may  sometimes  be  employed  with  advantage. 

If  the  uterus  lies  posterior,  the  sound  can  usually  be  introduced 
directly  with  its  concavity  backward. 

What  are  the  uses  of  the  uterine  sound  ? 
(a)  To  determine — 1.  The  length  of  uterine  canal. 

2.  Its  permeability. 

3.  Its  direction, 

4.  Condition  of  endometrium. 

5.  Growths  in  uterus. 

6.  Relation  of  uterus  to  tumors. 
(h)  To  replace  a  displaced  uterus. 

The  mobility  of  the  uterus  and  the  relation  of  cervix   and  body 
should  be  determined  by  the  bimanual,  not  by  the  sound. 
The  sound  is  wisely  much  less  used  now  than  formerly. 

What  are  the  danglers  in  the  use  of  the  sound  ? 

1.  Pelvic  peritonitis  or  cellulitis,  from  introduction  of  sepsis. 

2.  Abortion. 

3.  Hemorrhage,  especially  in  malignant  disease. 

4.  Perforation  of  uterine  walls. 


58  ESSENTIALS   OF   GYN^ICOLOGT. 


Uterine  Probe. 

Give  its  description  and  uses. 

The  uterine  probe  is  usually  a  slimmer  instrument  than  the  sound, 
made  of  silver,  hard  rubber  or  whalebone,  with  end  slightly  bulbous. 
Except  in  cases  of  stenosis,  it  is  harder  to  introduce  than  the  sound, 
and  of  less  general  value.  It  should  be  introduced  by  sight,  while 
cervix  is  steadied  with  a  tenaculum. 


Dilators. 

What  are  the  methods  of  dilating*  the  cervical  canal  ? 

1.  By  tents. 

2.  By  graduated  hard  dilators, 

3.  By  dilators  of  the  glove-stretcher  variety. 

4  ^y  elastic  dilators — ^Barnes'  bag  or  Allen's  pump. 

Tents. 

What  do  you  mean  by  a  tent  as  employed  in  g-ynaBcolog-y  ? 
Give  the  varieties  in  use. 

A  tent  is  a  cone  of  some  expansile  material,  which,  by  absorption 
of  moisture,  exj^ands  after  introduction  into  the  cervix  sufficiently, 
both  in  extent  and  force,  to  dilate  the  canal. 

There  are  several  varieties  of  tents  in  use,  named  according  to 
their  material. 

1.  Sponge. 

2.  Sea-tangle  (Laminaria  digitata). 

3.  Tupelo  (Nyssa  aquatHis). 

4.  Cornstalk. 

What  are  the  merits  of  each  ? 

The  sponge  tent  expands  easily,  but  it  is  the  most  dangerous  of 
all,  fix)m  the  fact  that  it  absorbs  so  readily  material  which  easily 

becomes  septic. 

The  sea-tangle  tent  is  less  dangerous  than  the  preceding,  and 
dilates  well,  but  it  expands  unevenly,  and  its  edges  are  rough  after 
expansion. 


INSTRUMENTS — TENTS.  59 

The  tupelo  tent  is  tlie  best  of  all.   It  expands  evenly  and  smoothly, 
and  is  the  least  liable  to  cause  sepsis. 

The  cornstalk  is  feeble  in  action  and  seldom  used. 

W^iat  are  the  indications  for  the  use  of  tents  ? 

1.  To  dilate  the  cei-vical  canal  for  purposes  of  diagnosis  or  opera- 
tion. 
2    To  check  hemorrhage. 

What  are  the  merits  of  tents  for  these  uses  1 

The  employment  of  tents  has  greatly,  and  very  wisely,  diminished 
of  late.  For  diagnostic  purposes  they  are  still  occasionally  employed 
to  dilate  the  ceiTical  canal,  so  that  the  finger  can  be  introduced,  but 
they  are  dangerous,  slow  and  painful,  and  we  have,  in  most  cases, 
better  means,  in  dilators  of  the  glove-stretcher  variety,  for  accom- 
plishing the  same  result. 

"  The  use  of  tents  to  check  hemorrhage  was  chiefly  in  abortion  ;  the 
dilatation  of  the  canal  being  sought  for  at  the  same  time.  We  now 
have  better  means. 

What  are  the  preliminaries  to  the  use  of  tents  ? 

All  antiseptic  precautions  should  be  observed.  Patient  should 
have  an  antiseptic  vaginal  douche. 

You  should  determine  accurately  the  position  of  the  uterus. 

Tents  should  be  curved  to  the  direction  of  the  canal. 

A  string  should  be  passed  through  the  tent,  for  ease  in  with- 
•drawal. 

Patient  should  be  in  Sims'  position. 

How  would  you  introduce  a  tent  ? 

1.  Introduce  Sims'  speculum ;  di-aw  down  cervix  with  volseUa, 
then  taking  the  tent  in  a  pair  of  dressing  forceps  or  on  a  tent  car- 
rier, pass  it  into  cemcal  canal  by  sight ;  insert  a  tampon  and  give 
an  opium  suppository. 

What  should  be  the  future  treatment  of  the  case  ? 

Tents  should  not  be  left  in  over  6-12  hom-s  ;^  sponge  tents  not 
over  6  hours.     In  removing  a  tent,  do  not  rotate  it. 

Patient  must  remam  in  bed  for  24  hours,  and  not  leave  the  house 
for  3-4  days. 


60  ESSENTIALS   OF  GYNECOLOGY. 

Graduated  Hard  Dilators. 

Describe  them. 

There  are  several  varieties  in  common  use,  among  whicli  are  Peas- 
lee's,  Kammerer's,  Hank's,  etc. 

The  first  two  resemble  male  sounds,  except  that  the  curve  is  less 
acute,  and  at  2J  inches  there  is  a  bulb. 

Hank's  dilators  consist  of  two  sounds  on  each  handle,  one  at  each 
end.     They  are  often  made  in  sets  of  six  and  of  hard  rubber. 

Ordinary  male  sounds,  Nos.  15  to  18,  French,  may  often  be  sub- 
stituted for  the  dilators  just  mentioned. 

What  are  indications  for  the  use  of  graduated  hard  dilators  ? 

1.  By  themselves  to  dilate  a  stenosis  of  the  cervix  causing  dys- 
menorrhoea  or  steiility.  Under  stenosis  here  is  included  that  caused 
by  flexions. 

2.  To  maintain  a  dilatation  produced  by  one  of  the  more  power- 
ful dilators. 

Describe  the  mode  of  employment  of  these  graduated  hard 
dilators. 

Place  the  i^atient  in  the  dorsal  position ;  thoroughly  cleanse  the 
vagina  and  expose  the  cervix  with  a  speculum  ;  draw  down  and  hold 
cervix  with  a  tenaculum  or  volsella ;  introduce  dilator  by  sight,  as 
you  would  the  uterine  sound,  beginning  with  the  smallest  size  and 
increasing  to  the  largest.  Pack  the  vagina  loosely  with  iodoform 
gauze  or  sterilized  gauze. 

In  employing  these  graduated  dilators  for  stenosis  of  cervix 
causing  obstructive  dysmenorrhcea,  how  often  should 
they  be  introduced? 

It  is  usually  necessary  to  introduce  them  once  a  week  during  the 
first  month,  and  once  or  twice  a  month  for  a  few  months  afterward  ; 
exercising  each  time  the  same  antiseptic  precautions. 

Describe  the  dilators  of  the  glove-stretcher  variety. 

The  two  chief  styles  of  these  are  the  Sims  and  Ellinger's ;  in  the 
latter  of  which  the  blades  are  caused  to  move  parallel,  and  on  the 
handle  there  is  a  graduated  scale.  There  are  numerous  modifica- 
tions of  these  dilators,  among  which  may  be  mentioned  Wylie's  and 
GoodeU's. 


INSTRUMENTS— GRADUATED   HARD   DILATORS.  61 

What  are  the  indications  for  the  employment  of  these  dila- 
tors? 

The  same  indications  obtain  as  for  the  preceding,  and  in  addition 
where  a  more  complete  dilatation  of  the  ceiTix  is  desired. 

The  first  and  more  complete  dilatation  is  often  performed  with  a 
dilator  of  this  class,  and  then  the  dilatation  maintained  by  the 
graduated  hard  dilators. 

What  are  the  preliminaries  to  the  use  of  the  glove-stretcher 
dilators  ? 

The  patient  should  have  an  antiseptic  douche,  and  for  complete 
dilatation,  anaesthesia. 

Describe  the  method  of  employing  these  dilators. 

The  patient  is  usually  placed  in  the  dorsal  position.  Retract  the 
perineum  with  a  Simon's  speculum  ;  thoroughly  cleanse  the  vagina 
and  cervix ;  draw  down  and  steady  the  cervix  with  a  bullet  forceps 
and  introduce  dilator  to  the  shoulder,  separate  blades  gradually  to 
the  desired  extent,  being  careful  that  the  instrument  does  not  slip 
suddenly  and  lacerate  the  cervix.  While  most  of  the  dilatation  is 
performed  in  the  lateral-diameter  of  the  cervix,  it  is  often  well  to 
rotate  the  dilator  and  dilate  somewhat  in  other  diameters.  The 
dilatation  may  also  be  performed  with  the  patient  in  Sims'  posi- 
tion and  with  the  aid  of  Sims'  speculum. 

To  what  extent  should  you  carry  the  dilatation? 

Usually  from  J  to  1  inch. 


62  ESSENTIALS   OF   GYNECOLOGY. 

ELASTIC  DILATORS. 
Barnes'  Bags,  Allen's  Pump. 

Describe  them  and  the  method  of  using^  them. 

They  consist  of  India-rubber  bags,  of  different  sizes,  the  former 
being  fiddle-shaped,  the  latter  more  elongated.  They  are  intro- 
duced under  strict  antiseptic  precautions,  in  a  collapsed  condition, 
and  are  then  slowly  distended  with  air  or  water,  usually  the  former  ; 
the  Barnes'  bags  by  means  of  a  Davidson's  syringe,  Allen's  by  the 
pump. 

What  are  the  advantages  of  these  elastic  dilators  ? 

Their  method  more  closely  resembles  the  physiological  method  of 
dilating  the  cervix ;  the  dilatation  can  be  made  extensive  ;  the 
danger  of  laceration  of  the  cervix  is  slight. 

What  are  the  dangers  of  mechanical  dilatation  ? 

Laceration  of  the  cervix. 
Endometritis. 
Salpingitis. 
Peritonitis. 

The  Curette. 

Describe  it. 

The  curette  consists  usually  of  a  loop  of  wire,  either  blunt  or 
sharp,  on  a  rather  long  shank,  used  for  scraping  irregularities  or  new 
growths  from  the  endometrium. 

Occasionally,  it  is  made  like  a  small  cup,  with  a  sharp  edge,  at- 
tached to  a  long  shank.     Simon's  spoon  is  of  this  description. 

What  are  the  varieties  in  common  use  ? 

Thomas'  wire  loop,  dull  and  flexible. 
Sims'  curette. 
Recamier  curette. 
Simon's  spoon. 

What  is  the  value  of  the  curette  ? 

It  is  a  very  valuable  instrument,  both  for  diagnosis  and  treatment. 
a.  For  diagnosis,   to  scrape  away  some  of  the  contents  of  the 
uterus  for  examination,  to  determine  the  cause  of  hemorrhage. 


VULVITIS.  63 

h.  For  treatment,  to  scrape  away  villous  growths,  which,  by  theu 
vascularity,  easily  cause  hemorrhage. 

In  malignant  disease  of  the  uterus,  the  curette  is  also  of  value  to 
remove  sloughing  masses. 

What  are  the  preliminaries  to  the  use  of  the  curette  ? 

The  patient  should  be  anaesthetized,  placed  in  the  dorsal  position 
on  a  Kelly's  pad,  and  knees  supported  with  a  leg-holder.  The  va- 
gina should  be  scrubbed  with  soap  and  water ;  an  antiseptic  douche 
should  be  given,  and  all  antiseptic  precautions  should  be  observed 
in  regard  to  instruments,  hands,  etc. 

The  perineum  should  be  retracted  with  a  Simon's  or  Sims'  spec- 
ulum ;  cervix  drawn  down  and  steadied  with  a  bullet  forceps,  then 
dilated. 

A  gentle  curettage  can  sometimes  be  performed  without  ansesthe- 
sia,  but  for  the  thorough  operation  ansesthesia  is  usually  necessary. 
Describe  briefly  the  method  of  curettage. 

After  dilatation  of  the  cervix,  the  curette  should  be  introduced 
very  gently  until  the  fundus  of  the  uterus  is  reached,  then  with- 
drawn with  the  working  edge  of  the  instrument  pressed  firmly 
against  the  wall  of  the  uterus.  This  process  is  repeated  until  the 
walls  of  the  uterus  feel  smooth.  The  cavity  of  the  uterus  should 
then  be  irrigated  with  an  aseptic  or  antiseptic  solution.  A  strip  of 
iodoform  gauze  has  of  late  been  introduced  into  the  uterus  after 
curetting  and  irrigating  ;  this  is  of  advantage  in  draining  and  caus- 
ing contraction  of  the  uterus.  The  patient  should  be  confined  to 
bed  for  several  days. 

What  are  the  dangers  of  the  curette  ? 

Perforation  of  the  uterus ;  septic  inflammation  of  the  uterus  or 
its  adnexa ;  peritonitis. 

Vulvitis. 

What  are  the  varieties  ? 

r  1.  Simple  catarrhal,  acute  or  chronic 
a.  Occurring    in  both    |  2.  Gonon-hoeal ; 

3.  Phlegmonous  ; 

4.  Diphtheritic ; 

5.  Gangrenous ; 
h.  Occurring  in  adults  :  Follicular. 


children  and  adults  : 


64  ESSENTIALS    OF   GYNECOLOGY. 

I.  Acute  Simple  Catarrhal  Vulvitis, 

What  are  the  causes  ? 

Lack  of  cleanliness  ; 

Strumous  diathesis  ; 

Discharges  from  cervix,  or  vagina ; 

Injuries  or  friction  from  exercise  ; 

Masturbation  ; 

Awkward,  or  excessive  coitus  ; 

Pregnancy ; 

Foreign  bodies ; 

Parasites ; 

Acute  exanthemata. 

What  are  the  symptoms  ? 

General  malaise  ;  some  local  pain  and  burning  ;  parts  are  oedema- 
tous,  congested,  covered  with  a  glairy,  mucous,  excoriating  discharge, 
which  may  extend  to  the  urethra. 

What  is  the  treatment  ? 

Rest  in  bed  ;  warm  sitz-baths ;  lead  and  opium  wash  frequently 
apphed  to  the  vulva  ;  lint  soaked  in  it  kept  between  the  labia.  Bis- 
muth, starch,  or  bora,x  may  with  advantage  be  dusted  on  the  vulva 
in  the  intervals  between  the  applications  of  the  lead  and  opium 
wash.  If  the  vulvitis  is  from  ascarides,  employ  enemata  of  infusion 
of  quassia,  ^ij-Oj. 

Chronic  Catarrhal  Vulvitis. 

Describe  its  occurrence  and  course. 

Catarrhal  vulvitis  in  children  is  most  apt  to  be  chronic  ;  it  is  seen 
most  frequently  in  strumous  children,  often  with  no  history  of  the 
acute  stage. 

What  are  the  symptoms  ? 

1.  Discomfort  in  walking  and  in  micturition  ; 

2.  Pruritus ; 

3.  Stains  on  linen. 

What  is  the  treatment  ? 

Build  up  the  constitution  by  tonics  and  fresh  air  ;  observe  cleanli- 
ness ;  if  much  discomfort,  use  lead  and  opium  wash,  followed  later 


VULVITIS.  65 

by  nitrate  of  silver  (gr.  x-^j)  applied  to  the  vulva  ;  bismuth  or 
borax  being  dusted  on  between  the  lotions. 

II.    G-ONORRHCEAL  VULVITIS. 

What  is  the  etiology  ? 

It  is  produced  either  directly  by  intercourse  with  one  who  has 
contracted  gonorrhoea,  or  indirectly  by  soiled  linen,  instruments,  etc. 

What  is  the  diagnostic  value  of  Neisser's  gonococcus,  found 
in  the  discharge  ? 
Dr.  W.  J.   Sinclair,  in  his  work  on  "  Gronorrhoeal  Infection  in 
Women,"  arrives  at  the  following  conclusions  : — 

1.  "If  gonococci  are  present  in  the  discharge  from  an  inflamed 
mucous  membrane,  the  discharge  is  of  gonorrhoeal  origin." 

2.  "A  secretion  containing  gonococci,  when  brought  into  contact 
with  a  mucous  membrane  capable  of  infection,  gives  rise  with  cer- 
tainty to  a  gonorrhoeal  inflammation  ;  and  conversely,  a  secretion, 
whatever  its  origin  may  be,  which  does  not  contain  gonococci,  is 
incapable  of  giving  rise  to  a  gonorrhoeal  inflammation." 

What  is  the  differential  diagnosis  between  gonorrhoeal  vul- 
vitis and  acute  simple  catarrhal  vulvitis  ? 

In  gonorrhoeal  vulvitis,  the  onset  is  more  violent ;  more  fever, 
pain  and  oedema;  the  inflammation  extends  up  the  vagina  and 
urethra ;  pus  can  often  be  pressed  out  of  urethra  ;  gonococci  can  be 
found  in  the  discharge  ;  often  warts  or  buboes  are  present,  and 
sometimes  gonorrhoeal  rheumatism. 

What  is  the  treatment  of  gonorrhoeal  vulvitis  ? 

Keep  patient  quiet;  give  light  diet;  keep  bowels  open;  disinfect 
the  parts  with  bichloride  1-5000,  or  lysol  1-100  or  200 ;  then  have 
the  parts  irrigated  every  hour  or  two  with  borax  water  3j-0j.  If 
discomfort  is  very  great,  lead  and  opium  wash  may  be  frequently 
applied  to  the  vulva,  and  patient  may  take  warm  sitz-baths.  The 
labia  should  be  kept  separated  with  lint  or  gauze  smeared  with  some 
simple  antiseptic  ointment. 

If  the  vulvitis  tends  to  become  chronic,  apply  nitrate  of  silver, 

gr.  x-xx-.^j. 
6 


66  ESSENTLILS   OF  GYNiECOLOGY. 

III.  Phlegmonous  Vulvitis. 

What  is  the  etiology  ? 

It  may  arise  from  the  following  : — 
Traumatism ; 
Irritating  discharges ; 
Acute  exanthemata ; 
FuiTinculosis. 

What  are  the  symptoms  ? 

a.  Subjective  :  Heat  and  pain,  increased  by  standing  or  walking. 
h.  Objective  :    Congestion,  sweUing,  induration ;   later,  suppura- 
tion. 

From  what  must  you  differentiate  phlegmonous  vulvitis  ? 

a.  Pudendal  hernia ; 
h.  Dislocated  ovary ; 

c.  Hydrocele  of  round  ligament ; 

d.  Haematoma  of  vulva. 

How  would  you  differentiate  phlegmonous  vulvitis  from  pu- 
dendal hernia  ? 

Phlegmonous  Vulvitis         vs.  Pudendal  Hernia. 

Signs  of  acute  inflammation.  None    unless    strangulated,    or 

injured. 
Dullness  on  percussion.  Tympanitic  on  percussion. 

No  impulse  on  coughing.  Impulse  on  coughing. 

Not  reducible.  Usually  reducible. 

History  of  traumatism,  etc.  History  of  strain. 

How  would  you  differentiate  phlegmonous  vulvitis  from  a 
dislocated  ovary  ? 

Phlegmonous  Vulvitis         vs.  Dislocated  Ovary. 

Signs  of  acute  inflammation.  Usually  absent. 

Gradual  development.  Sudden  development. 

No  especial  exacerbation  during      Larger  and  more  sensitive  during 

menstruation.  menstruation. 

No  sense  of  ovarian  compression      Peculiar  sensation  when  pressed. 

when  pressed  upon. 
Not  the  shape  of  an  ovary.  Has  the  shape  of  an  ovary. 


VULVITIS.  67 

How  would  you  diiFerentiate  pMegmonous  vulvitis   from 
hydrocele  of  the  round  ligament  ? 

Phlegmonous  Vulvitis  vs.  Hydrocele  of  Round  lAgament. 

Signs  of  acute  inflammation.  No  signs  of  acute  inflammation. 

Opaque.  Translucent. 

Never   communicates  with    ab-       Sometimes  communicates  with 
dominal  cavity.  abdominal  cavity. 

How  would  you   diiferentiate  phlegmonous  vulvitis   from 
haematoma  of  vulva  ? 
Phlegmonous  Vulvitis  vs.  HcemMtoma  of  Vulva. 

G-radual  formation.  Sudden  onset. 

Less    frequent    during   parturi-      More  frequent   during  parturi- 
tion, tion. 

Color,  red.  Color,  purplish. 

First  hard,  then  soft.  First  soft,  then  hard. 

Less  often  preceded  by  varicosi-      More  often  preceded  by  varicosi- 
ties, ties. 

What  is  the  treatment  of  phlegmonous  vulvitis  ? 

Tonics:  Arsenic,  quinine,  etc. 

Wet  antiseptic  dressings,  as  gauze  soaked  in  cool  alum-acetate 
solution.    When  pus  has  formed,  open,  drain,  and  dress  antiseptically. 

IV.  Diphtheritic  Vulvitis. 
Give  the  etiology,  symptoms,  and  treatment. 

True  diphtheritic  vulvitis  is  a  rare  affection,  but  occasionally  occurs 
as  an  expression  of  constitutional  diphtheria.  The  membrane  some- 
times appears  first  on  the  vulva  ;  it  resembles  that  usually  found  in 
the  throat.  The  constitutional  symptoms  are  those  of  diphtheria,  and 
should  be  treated  as  such ;  the  local  condition  demands  antiseptics. 

V.  Gangrenous  Vulvitis. 
Give  the  etiology  and  treatment. 

Gangrenous  vulvitis  is  most  frequently  found  complicating  preg- 
nancy, severe  types  of  acute  exanthemata,  and  very  violent  cases  of 
vulvitis  of  other  varieties.  The  treatment  consists  of  constitutional 
tonics  and  local  antiseptics. 


68  ESSENTIALS   OF  GYNECOLOGY. 

YI.  Follicular  Vulvitis. 

Give  the  patholog^y. 

Follicular  vulvitis  is  an  inflammation  of  the  mucous  and  sebaceous 
glands  and  hair  follicles  of  the  vulva  ;  all  may  be  simultaneously 
affiected,  or  one  set  alone  involved. 

What  is  the  etiology  ? 

It  occurs  only  in  adults  ;  any  of  the  causes  of  simple  acute  catarrhal 
vulvitis  may  produce  it ;  among  the  most  common  are  the  follow- 
ing :— 

a.  Lack  of  cleanliness  ; 

h.  Discharges  from  above,  especially  senile  leucorrhoea ; 

c.  Pregnancy ; 

d.  Acute  exanthemata. 

What  are  the  symptoms  ? 

a.  Subjective : — 

Local  heat  and  pain ; 
Pruritus  ; 

Increased  secretion ; 
Hyperaesthesia ; 

Vaginismus  occasionally  present ; 

Vulvar  extremity  of  urethra  is  sometimes  affected,  then  ardor 
urinae  results. 
h.  Objective : — 

The  mucous  membrane  appears  very  red  in  spots,  resembling  the 
papillae  of  the  tongue.  When  the  sebaceous  glands  and  hair  follicles 
are  chiefly  affected,  they  will  be  found  as  httle  round  red  papillae,  scat- 
tered over  labia  and  base  of  prepuce  and  clitoris,  not  on  vestibule ; 
later,  a  drop  of  pus  appears  in  the  apex  of  these  papillae  ;  they  then 
disappear. 

How  would  you  treat  a  case  of  follicular  vulvitis? 

Pay  strict  attention  to  cleanliness ;  during  the  acute  stage  use 
mild  antiseptic  lotions,  as  borax  water  (3j-0j)  or  alum-acetate  solu- 
tion; later,  apply  nitrate  of  silver  (gr.  x-,^j).  Bismuth  or  calomel 
may  be  used  as  a  dusting  powder ;  keep  labia  separated. 


CYST  AND  ABSCESS   OF  VULVO- VAGINAL  GLAND.  69 

Cyst  and  Abscess  of  Vulvo-vaginal  Gland, 

Cyst  of  Yulvo-vagin'al  Gtland. 

Give  the  etiology  and  pathology. 

A  cyst  of  the  Barthohnian  or  vulvo-vaginal  gland  is  formed  by  a 
distention  of  the  duct,  or  gland  itself,  caused  by  any  occlusion  of  the 
duct,  especially  from  inflammation,  either  simple  catarrhal  or  gon- 
orrhoeal.  A  cyst  of  the  duct  is  more  elongated  than  of  the  gland 
itself ;  a  cyst  of  the  gland  is  occasionally  multiple. 

Abscess  of  the  Vulvo-vaginal  Gland. 

What  is  the  etiology  1 

The  causes  of  a  vulvitis  may  produce  abscess  of  the  vulvo-vaginal 
gland  ;   gonorrhoea  is  the  most  common  cause. 

What  are  the  symptoms  ? 

Pain  ;  heat ;  swelling  and  redness,  especially  near  orifice  of  duct ; 
it  is  tender  on  pressure  ;  at  first  hard,  later  fluctuating. 

How  could  you  differentiate  a  cyst  from  an  abscess  of  the 
vulvo-vaginal  gland  ? 

Cyst  vs.  Abscess. 

Gives  no  signs  of  inflammation.       Shows  inflammation . 
Insensitive  to  pressure.  Sensitive  to  pressure. 

Duration  long.  Duration  shorter. 

What  is  the  treatment  of  a  cyst  of  the  vulvo-vaginal  gland  ? 

The  usual  treatment  is  to  excise  an  elliptical  area  of  mucous  mem- 
brane over  the  sac  on  its  inner  surface  ;  this  exposes  the  sac ; 
now  cut  out  a  large  elHpse  from  it ;  empty  the  sac,  pack  it  with 
iodoform  gauze,  and  apply  an  antiseptic  outside  dressing. 

A  better  plan  is  usually  to  dissect  out  the  whole  sac,  if  possible, 
and  bring  together  the  edges  of  the  wound  with  catgut ;  then  apply 
an  antiseptic  dressing  as  before. 

From  what  may  you  get  considerable  hemorrhage  in  extir- 
pating the  sac  ? 
From  the  transversus  perinei  artery,  and  from  the  bulbs  of  the 
vagina. 


70  ESSENTIALS  OF  GYNECOLOGY. 

How  would  you  treat  an  abscess  of  the  vulvo-vaginal  gland? 

Before  the  presence  of  pus  is  detected,  keep  the  patient  quiet  in 
bed ;  applj'^  soothing  lotions  like  alum-acetate  solution.  As  soon 
as  pus  is  detected,  proceed  as  with  the  cyst  till  sac  is  opened, 
then  with  a  sharp  curette  scrape  the  interior  of  sac  wall ;  irrigate 
with  bichloride  (1-1000) ;  pack  with  iodoform  gauze,  and  apply  an 
antiseptic  outside  dressing  of  iodoform  gauze,  bichloride  gauze, 
absorbent  cotton  and  a  T-bandage. 

From  what  must  you  differentiate  vulvo-vaginal  cyst  or 
abscess  ? 

From  hernia  and  phlegmonous  vulvitis. 

How  would'  you  differentiate  vulvo-vaginal  cyst  or  abscess 
from  hernia  ? 

Cyst  or  Abscess  vs.                   Hernia. 

No  imjDulse  on  coughing.  Impulse  on  coughing. 

Irreducible.  Usually  reducible. 

DuU  on  percussion.  Tympanitic  on  percussion. 

Abscess  shows  signs  of  inflam-  None,   unless    strangulated,   or 

mation.  injured. 

More  circumscribed.  Less  circumscribed. 

How  would  you  differentiate  abscess  of  vulvo-vaginal  gland 
from  phlegmonous  vulvitis  ? 

The  vulvo-vaginal  abscess  is  more  distinctly  circumscribed  and 
globular  ;  the  phlegmonous  vulvitis  is  more  diffuse. 


Pudendal  Hernia. 

Describe. 

The  process  of  peritoneum  which  follows  the  round  ligament 
through  the  inguinal  canal  to  its  termination  in  the  labixmi  majus  is 
usually  obliterated  at  bui;h  ;  occasionally  this  obliteration  does  not 
occur,  and  this  channel,  called  the  canal  of  Nuck,  furnishes  a  path 
for  hernia.  The  hernia  may  consist  of  intestine,  omentum,  ovary  oi 
bladder.     The  uterus  has  even  been  said  to  follow  this  canal. 

What  are  the  causes  ? 

Blows,  falls,  coughing  or  violent  muscular  exertion. 


PUDENDAL  HEMATOCELE.  71 

What  are  the  symptoms  ? 

The  patient  experiences  a  feeling  of  discomfort,  especially  on 
walking,  and  finds  a  swelling,  which,  if  intestine,  presents  the  fol- 
lowing features :  It  gives  an  impulse  on  coughing ;  is  tympanitic 
on  percussion ;  can  usually  be  reduced,  and,  unless  strangulated, 
or  injured,  presents  no  signs  of  inflammation. 

If  the  hernia  consists  of  an  ovary,  it  gives  the  ovarian  sensation 
on  pressure,  and  its  size  and  tenderness  are  both  increased  during 
menstruation. 

What  is  the  treatment  ? 

Place  patient  on  her  back,  with  knees  elevated  ;  reduce  by  gentle 
taxis,  if  possible,  and  apply  a  suitable  truss.  If  strangulation  has 
occurred,  a  surcfical  operation  is  necessary.  If  the  hernia  consists 
of  an  ovary  which  has  become  adherent,  protect  it  from  pressure  by 
a  hollow  pad,  or  if  it  occasions  great  distress,  remove  it. 

Pudendal  Haematocele. 

What  are  the  synonyms  ? 

Haematoma  or  thrombus  of  vulva. 

Define. 

Pudendal  haematocele  (better  haematoma)  consist  of  an  effusion 
of  blood  into  the  tissue  of  the  vulvo-vaginal  region,  usually  into  one 
labium,  or  into  the  areolar  tissue  surrounding  the  vaginal  walls. 

What  is  the  etiology  ? 

Pudendal  haematocele  is  piedisposed  to  by  any  condition  causing, 
or  accompanied  by,  a  dilatation  of  the  vessels  of  the  vulva  : — 

Pregnancy ; 
Tumors; 
Varicocele ; 
Labor. 

The  exciting  causes  are  blows,  falls,  muscular  efforts,  etc. 

Describe  the  symptoms  and  course. 
The  patient  experiences  pain  of  a  tearing  character,  which,  if  the 


72  ESSENTIALS   OF   GYNECOLOGY. 

effasion  is  large,  may  be  accompanied  by  faintness.  Sometimes  tbe 
eiFusion  presses  on  tlie  uretbra  and  causes  difficulty  in  micturition. 
Tbe  swelling  is  at  first  soft ;  later,  bard. 

If  small,  it  is  usually  absorbed  ;  it  sometimes  remains  for  a  long 
time ;  sometimes  suppurates. 

How  would  you  differentiate   pudendal  hsematocele  from 
hernia  ? 

Pudendal  Hcematocele  vs.                   Hernia. 

History.  Histoiy. 

No  impulse  on  cougbing.  Impulse  on  cougbing. 

Dull  on  percussion.  Tympanitic. 

Irreducible.  Usually  reducible. 

First  soft,  tben  bard.  More  uniform. 

How  would  you  treat  a  case  of  pudendal  haematocele  ? 

While  effusion  is  in  progress,  apply  ice  and  pressure.  If  tbe 
effusion  is  large,  occurs  during  labor  and  obstracts  tbe  passage  of  tbe 
bead,  incise,  turn  out  tbe  clots  and  pack  witb  iodoform  gauze.  If 
the  effusion  is  small,  apply  soothing  lotions  like  alum-acetate  solution ; 
if  suppuration  occurs  or  if  absorption  is  long  delayed,  incise,  irrigate 
witb  an  antiseptic  solution,  and  pack  witb  iodoform  gauze. 


Hemorrhage  from  Vulva. 

What  is  the  etiology  ? 

The  predisposing  causes  are  tbe  same  as  for  pudendal  bgemato- 
cele  and  haematocele  itself.   Tbe  existing  causes  are  tbe  following  : — 
Violent  muscular  efforts ; 
Blows  ; 
Punctures  or  lacerations. 

What  is  the  treatment? 

If  it  is  a  mptured  haematocele,  incise,  turn  out  tbe  clots  and  pack  ; 
otherwise,  catch  bleeding  points  and  ligature,  or  apply  pressure, 
assisted  by  a  tampon  in  the  vagina. 


ECZEMA  OF  THE  VULVA.  73 


Skin  Diseases  AflFecting  the  Vulva. 

What  are  the  most  common? 

Erythema  and  eczema  are  most  frequently  seen  ;  the  latter  may 
be  acute  or  chronic. 


Erythema  of  the  Vulva. 

Give  the  etiology,  symptoms  and  treatment. 

Etiology. — Erythema  is  most  apt  to  occur  in  fleshy  people,  espe- 
cially in  hot  weather.     The  exciting  causes  are  : — 
Lack  of  cleanliness ; 
Irritating  discharges  ; 
Exercise. 
Symptoms. — ^The  parts  become  red,  sensitive,  often  excoriated  and 
painful,  especially  in  walking. 
Treatment. — Cleanliness ; 

Attention  to  bladder  and  urine  ; 
Desiccating  powders,  such  as  bismuth  subnitrate, 
oxide  of  zinc,  or  calomel. 

Eczema  of  the  Vulva. 

Give  the  etiology. 

Eczema  is  predisposed  to  by  functional  disturbance  of  the  gastro- 
intestinal tract,  gout  or  rheumatism  ;  it  is  especially  apt  to  occur  in 
women  near  the  menopause.  The  most  frequent  exciting  cause  is 
an  irritating  discharge  from  the  cervix  or  vagina. 

What  are  the  symptoms  ? 

The  disease  may  be  acute  or  chronic.  In  the  acute  form,  the  parts 
become  reddened  and  oedematous  ;  vesicles  appear,  break  and  dis- 
charge a  thick,  tenacious  fluid,  which  forms  crusts.  The  subjective 
symptfjms  are  severe  burning  and  itching. 

In  the  chronic  form,  the  parts  become  thickened  and  scaly ;  the 
subjective  symptoms  resemble  those  of  the  acute,  but  are  a  little 
less  marked. 


74  ESSENTIALS  OF  GYNECOLOGY. 

What  is  the  treatment  ? 

In  the  acute  form,  observe  strict  cleanliness  ;  if  the  burning  is  very 
severe,  use  alkaline  sitz-baths  and  sedative  lotions ;  later,  or  at  first 
if  burning  and  itching  are  not  intense,  an  ointment  like  the  follow- 
ing is  very  good  :  — 

R.    Acidi  salicylici, gr.  xv, 

Zinci  oxidi,   .    .    .    » 3ij  ss, 

Pulv.  amyli, .^  ij  ss, 

Petrolati, ^j. 

M.    Sig. — Apply  locally. 

In  the  chronic  form,  use  the  same  treatment  during  the  exacerba- 
tions as  for  the  acute  ;  later,  an  ointment  containing  oil  of  cade  will 
be  found  of  value. 

What  are  the  most  common  parasites  found  on  the  vulva  ? 

The  pediculus  pubis,  or  crab  louse,  is  the  parasite  most  often  found 
infecting  the  vulva. 

The  acarus  scabiei,  or  itch  mite,  is  occasionally,  but  rarely,  found 
on  the  vulva  as  part  of  a  general  infection. 

Give  the  etiolog-y,  symptoms  and  treatment  of  infection  with 
pediculi  pubis. 

Etiology. — The  pediculus  pubis  is  almost  always  conveyed  directly 
from  person  to  person,  usually  in  sexual  intercourse. 

Symptoms. — There  is  burning  and  itching  ;^  often  an  eruption 
resembling  eczema.  The  diagnosis  is  made  by  finding  the  pediculus 
closely  adherent  to  the  roots  of  the  hair. 

Treatment — Any  one  of  the  following  : — 

Corrosive  sublimate,  1-1000 ; 
Tincture  of  delphinium ; 
Carbolic  5  per  cent,  solution. 

It  is  often  best  to  shave  the  pubes  before  applying  the  lotion  or 
ointment. 

Give  the  etiology,  symptoms  and  treatment  of  scabies  of  the 
vulva. 

Etiology. — The  acarus  scabiei  is  rarely  found  on  the  vulva,  but 
this  occasionally  occurs  as  part  of  a  general  infection. 


POINTED   CONDYLOMATA.  75 

Symptoms.  — There  is  an  intense  praritus,  worse  when  the  body  is 
warm.  The  diagnosis  is  made  by  finding  the  burrows  on  other  pai-ts 
of  the  body,  especially  between  the  fingers. 

Treatment. — A  warm  soap  and  water  bath,  followed  by  an  oint- 
dient  comjjosed  of  sulphur  alone,  or  combined  with  balsam  of  Peru. 


New  Growths  of  the  Vulva. 

Mention  the  principal  new  growths  occurring  on  the  vulva  ? 

a.  Papillomata — 

1.  Simple ; 

2.  Pointed  condylomata ; 

3.  Syphilitic  condylomata. 
h.  Cyst  of  vulvo-vagiual  gland. 

c.  Carcinoma. 

d.  Sarcoma. 

e.  Elephantiasis. 
/  Fibromata. 

g.  Lipomata. 
Ji.  Neuromata. 
^.   Lupus. 


Simple  Papillomata. 

What  is  the  etiology  and  treatment  ? 

Etiology. — A  simple  papilloma,  or  wart,  occurs  rarely  on  the 
vulva  ;  it  is  usually  congenital  and  of  little  imjDortance. 

Treatment. — It  may  be  destroyed  with  nitric  acid,  or  it  may  be 
excised  under  cocaine,  and  the  wound  closed  with  fine  sutures. 


Pointed  Condylomata. 

What  is  the  etiology  and  appearance  ? 

Pointed  condylomata,  or  gonorrhoeal  warts,  are  caused  by  the 
gonorrhoeal  poison  ;  they  are  always  multiple,  and  occur  most  fre- 
quently on  the  inner  surfaces  of  the  labia  majora,  on  the  perineum 
and  about  the  anus ;  they  are  of  a  grayish  color  and  often  pediculated ; 


76  ESSENTIALS  OF  GYNECOLOGY. 

their  summit  is  divided  into  pointed  lobules.  When  on  the  skin, 
they  are  sometimes  dry  and  hard ;  on  a  mucous  surface  they  are 
soft.  In  some  cases  pointed  condylomata  appear  to  arise  from  an 
irritating  discharge,  the  gonorrhoeal  character  of  which  cannot  be 
proved. 

What  is  the  treatment  of  pointed  condylomata  ? 

The  best  treatment  is  to  cut  them  oiF  with  scissors  or  knife  and 
touch  the  base  with  nitric  acid  ;  under  the  use  of  cocaine  this  may 
be  made  practically  painless. 

Syphilitic  Condylomata. 

What  is  the  etiology,  appearance  and  treatment  ? 

Syphilitic  condylomata,  or  mucous  patches,  are  the  result  of  the 
syphilitic  poison.  They  are  broad  and  flat,  situated  most  frequently 
on  the  inner  surface  of  the  labia  majora,  and  usually  covered  with  a 
grayish,  mucus-like  secretion.  According  to  Duhring,  they  some- 
times take  on  a  more  warty  growth. 
Treatment. — Cleanhness ; 

Calomel  locally ; 

Constitutional  treatment  for  syphilis. 

Pruritus  Vulvae. 

Define. 

Pruritus  vulvaD,  a  symptom  rather  than  a  disease  per  se,  consists 
of  an  irritation  of  the  nerves  of  the  vulva,  accompanied  by  intense 
itching,  at  first  localized,  later  extending,  from  the  mechanical  irrita- 
tion of  scratching. 

What  is  the  etiology  ? 

The  predisiDosing  causes  are  : — 

a.  Poor  health. 

h.  Disorders  of  the  digestive  tract. 

c.  Anything  producing  congestion  of  the  vulva,  such  a»— 

Pregnancy ; 

Tumors  in  neighborhood ; 

Diseases  of  uterus  or  appendages ; 

Menopause. 


PRURITUS  YULVJE.  77 

d.  Lack  of  cleanliness. 

The  exciting  causes  are  chiefly  the  following  : — 

1 .  Irritating  discharges  from  cervix,  vagina,  urethra  or  vulva. 

2.  Diabetic  urine. 

3.  Eniptions. 

4.  Parasites. 

5.  Masturbation. 

6.  Vegetations  on  vulva. 

What  are  the  symptoms  ? 

An  intense  itching,  at  first  only  at  intervals  after  active  exercise, 
over-indulgence  at  the  table,  lying  in  a  warm  bed,  or  sexual  inter- 
course. Later,  the  itching  becomes  constant ;  the  desire  to  scratch 
becomes  irresistible,  causing  the  patient  to  avoid  society ;  it  some- 
times leads  to  nervous  depression  and  melanchoha. 

What  is  the  treatment  ? 

Fii'st  ascertain  the  cause,  if  possible. 

Build  up  the  general  health. 

Regulate  the  diet. 

Observe  strict  cleanUness. 

Destroy  parasites  if  jDresent. 

If  sugar  present  in  the  urine,  give  sahcylate  of  soda. 

Treat  eruptions. 

If  there  is  an  acid  discharge  from  above,  tampon  vagina. 

Let  patient  use  frequent  warm  sitz-baths. 

Apply  any  one  of  the  following  : — 

Hot  lead  and  opium  wash  ; 
.  Carbolic  solution,  2-3  per  cent. ; 

Bismuth  or  calomel  dusted  on  vulva ; 

Nitrate  of  silver  (gr.  x-^j) ; 

Cocaine,  4  per  cent,  solution. 


78  ESSENTIALS   OF   GYN^Ct?LOGY. 

Hyperaesthesia  of  the  Vulva. 
Describe. 

This  consists  of  an  excessive  sensibility  of  the  nerves  supplying  the 
mucous  membrane  of  some  portion  of  the  vulva. 

What  is  the  etiology  ? 

The  menopause  seems  to  predispose  to  it ;  also  the  hysterical  and 
melancholic  state.  An  irritable  urethral  caruncle  sometimes  acts  as 
an  exciting  cause.     Often  no  cause  can  be  assigned. 

What  are  the  symptoms  ? 

Hyperaesthesia,  especially  about  the  vestibule  and  labia  minora ; 
there  is  no  pruritus,  and  signs  of  inflammation  are  absent  except 
occasional  erythematous  spots ;  dyspareunia  is  very  marked ;  the 
slightest  friction  causes  pain. 

What  is  the  treatment  ? 

Build  up  the  constitution  with  tonics,  change  of  air,  etc. 
Interdict  sexual  intercourse. 
Administer  the  bromides  internally. 
Externally  apply  one  of  the  following  : — 

Carbolic  lotion,  2-3  per  cent ; 

Nitrate  of  silver  solution  (gr.  x-xx-^j) ; 

Lead  and  opium  wash  ; 

Four  per  cent,  solution  of  cocaine. 

Vaginismus. 

Define. 

Sims  defined  vaginismus  as  "an  excessive  hyperaesthesia  of  the 
hymen  and  vulvar  outlet,  associated  with  such  involuntary  spasmodic 
contraction  of  the  sphincter  vaginae  muscle  as  to  prevent  coitus. ' ' 

What  is  the  pathology? 

There  are  usually  found  sensitive  papillae  about  the  base  of  the 
hymen  ;  an  hypertrophy  of  the  papillae  and  connective  tissue  of  the 
hymen  ;  occasionally  the  lesion  seems  to  be  at  a  distance,  as  in  the 
uterus  or  appendages  ;  sometimes  no  lesion  is  visible. 


COCCYGODYNIA.  79 

What  is  the  etiology  ? 

The  predisposing  causes  are — 

1.  A  narrow  vagina. 

2.  A  dense,  thick  hymen. 

3.  Malposition  of  the  vulva. 
The  exciting  causes  are — 

1 .  Disturbances  of  the  sexual  function. 

2.  Masturbation, 

3.  Inability  of  the  male  to  complete  the  sexual  act. 

What  is  the  treatment  ? 

Palliative. — Forcibly  dilate  the  hymen,  under  anaesthesia,  by  insert- 
ing and  separating  the  thumbs ;  then  insert  one  of  Sims'  gla,ss 
vaginal  plugs. 

Radical. — Excise  the  hymen  and  insert  one  of  Sims'  plugs. 

Coccygodynia. 

Define  and  give  the  etiology. 

Coccygodynia,  or  coccyodynia,  is  a  "  painftd  affection  of  the  mus- 
cles, tendons,  and  nerves  of  the  coccyx,  with  or  without  disease  of 
the  bone  itself"     (Mann). 

It  occurs  most  frequently  after  childbirth,  but  is  also  produced  by 
mechanical  causes,  such  as  blows,  falls,  kicks,  etc.  Among  other 
causes  are  disease  of  the  pelvic  organs,  rheumatism  and  gout.  Hys- 
teria largely  predisposes  to  it ;  in  some  cases  no  cause  can  be  assigned. 

What  are  the  symptoms? 

Pain  in  the  coccygeal  region,  increased  by  motion  bringing  into 
play  the  muscles  attached  to  the  coccyx ;  especially  rising  after  sit- 
ting, defecation,  coitus,  sometimes  even  walking. 

Pressure  on  the  coccyx  elicits  the  characteristic  pain. 

The  condition  must  be  differentiated  from  disease  of  the  rectum 
or  anus,  and  from  pure  hysteria. 

What  is  the  treatment  ? 

First  attend  to  the  general  condition,  rheumatism,  hysteria,  etc; 
if  this  fails,  we  have  two  operations  : — 

1.  Cutting  the  attachments  of  the  muscles  to  the  coccyx. 

2.  Extirpation  of  the  coccyx. 


80  ESSENTIALS   OF   GYNECOLOGY. 

Irritable  Urethral  Caruncle. 

Define. 

An  irritable  urethral  caruncle  is  a  deep  red  mass,  very  vascular 
and  sensitive,  situated  at  tlie  mouth  of  the  urethra,  or  just  within 
the  canal ;  it  consists,  according  to  Hart  and  Barbour,  of  dilated  capil- 
laries in  connective  tissue,  the  whole  being  covered  with  squamous 
epithelium. 

What  is  the  etiology  ? 

But  little  is  known  of  its  etiology ;  it  occurs  at  all  ages,  and  m 
both  married  and  single  women. 

What  are  the  symptoms  ? 

The  patient  complains  of  frequent  and  painful  micturition  ;  later, 
this  dysuria  increases,  and  pain  is  caused  by  walking,  pressure  or 
friction  of  any  kind.  Intercourse  causes  both  pain  and  hemorrhage. 
The  nervous  symptoms  are  well-marked  ;  hysteria,  melancholia,  etc. 

On  examination,  one  finds  a  raspberry-looking  mass  at  the  meatus ; 
it  is  very  sensitive  and  bleeds  easily  ;  it  may  be  single  or  multiple. 

From  what  must  you  differentiate  an  irritable   urethral 
caruncle,  and  how  ? 

From  polypi,  venereal  warts  and  prolapse  of  the  urethral  mucous 
membrane. 

Polypi  are  usually  higher  in  the  urethra,  are  less  vascular  and 
less  sensitive. 

Venereal  warts  are  less  vascular,  insensitive,  and  usually  accom- 
panied by  others.     The  history  may  aid. 

Prolapse  of  the  urethral  mucous  membrane  may  resemble  a 
caruncle  in  appearance,  but  it  usually  surrounds  the  meatus  more,  is 
less  vascular  and  less  sensitive,  is  continuous  with  the  urethral 
mucous  membrane,  and  can  usually  be  reduced. 

What  is  the  treatment  ? 

Employ  anaesthesia  ;  cut  off  the  caruncle  and  touch  the  base  with 
nitric  acid  or  the  actual  cautery.     You  may  ligate  before  cutting. 

What  is  the  prognosis  ? 

If  the  growth  is  single  and  near  the  meatus,  the  prognosis  is  good ; 
if  multiple  and  extending  up  the  urethra,  they  may  recur. 


MALFORMATIONS   OF  THE  VULVA.  81 

Prolapse  of  the  Urethral  Mucous  Membrane. 

Describe. 

Prolapse  of  the  urethral  mucous  membrane  may  involve  the  whole 
circumference  of  the  meatus,  or  only  a  portion  ;  if  the  latter,  it  is 
the  lower  portion  which  is  usually  affected  ;  a  slight  redundancy  at 
the  meatus  is  common  ;  a  prolapse  sufficient  to  form  a  tumor  is  rare. 
At  first  the  exposed  mucous  membrane  is  of  its  normal  pink  color  ; 
later  it  assumes  an  angry  red  color,  often  becomes  excoriated  and 
sensitive  ;  urethritis  and  cystitis  may  accompany  it. 

What  is  the  etiology  ? 

Frequent  child-bearing,  dilatation  of  the  urethra  and  a  lax  condi- 
tion of  the  tissue,  from  whatever  cause,  undoubtedly  predispose  to 
prolapse  of  the  urethral  mucous  membrane.  The  exciting  causes 
are  usually  vesical  and  rectal  irritation,  accompanied  by  straining. 

What  are  the  symptoms  ? 

Frequent  micturition,  which  soon  becomes  painful,  tenesmus,  and 
if  vesical  tenesmus  previously  existed,  it  becomes  much  aggravated. 

What  is  the  treatment  ? 

If  the  prolapse  is  recent,  an  attempt  at  cure  may  be  made  by 
reducing  the  mucous  membrane,  keeping  the  patient  quiet  in  bed, 
making  astringent  applications  to  the  urethra  and  removing  the 
cause  of  previous  vesical  or  rectal  tenesmus,  if  present. 

If  these  procedures  fail,  remove  the  prolapsed  portion  by  one  of 
the  following  methods: — 1.  If  small,  ligate  and  excise;  if  more 
extensive,  excise  the  redundancy  and  stitch  mucous  membrane  of 
urethra  to  the  border  of  the  meatus.  2.  Emmet's  "button-hole" 
operation.     The  first  method  is  usually  the  preferable  one. 


Malformations  of  the  Vulva. 

What  are  the  principal  malformations  of  the  vulva  ? 

1.  Absence  of  the  vulva. 

2.  Hypospadias,  in  which  the  posterior  wall  of  the  urethra  is 
defective. 

6 


82  ESSENTIALS   OF  GYNECOLOGY. 

8.  Epispadias,  in  which  the  anterior  urethral  wall  is  defective, 
usually  combined  with  a  defect  in  the  anterior  wall  of  the  bladder. 
4  The  clitoris  may  be  absent,  rudimentary,  or  hypertrophied. 

5.  The  labia  majora  may  be  absent,  rudimentary,  or  greatly  hyper- 
trophied, as  in  the  "  Hottentot  apron." 

6.  Less  often  the  labia  majora  may  be  hypertrophied. 

7.  True  hermaphroditism,  where  both  an  ovary  and  a  testicle  exist 
in  the  same  person,  although  very  rare,  is  said  to  occur  in  a  few  cases. 

8.  Pseudo-hermaphroditism,  where  the  external  genitals  alone 
resemble  those  of  both  sexes,  is  more  common. 

Diseases  of  the  Vagina. 

What  are  the  varieties  of  inflammation  of  the  vagina  ? 

lo  Simple  catarrhal  vaginitis,  or  colpitis. 

2.  Gronorrhceal. 

3.  Ulcerative,  senile  or  adhesive. 

4.  Diphtheritic. 

Simple  Catarrhal  Vaginitis. 

What  is  the  etiology  ? 

The  predisposing  causes  are — 

a.  General  bad  health. 

h.  Anything  causing  local  congestion,  as — 

Disease  of  heart  or  lungs  ; 

Disease  of  the  pelvic  organs ; 

Pregnancy. 
The  exciting  causes  are  : — 
a.  Irritating  discharges  from  the  cervix. 
h.  The  use  of  too  hot,  too  cold  or  irritating  douches. 

c.  Awkward  or  excessive  coitus. 

d.  Foreign  bodies,  as  pessaries,  tampons,  etc. 

What  are  the  symptoms  ? 

Simple  catarrhal  vaginitis  may  be  acute  or  chronic. 

The  subjective  symptoms  of  the  acute  are  a  feeling  of  heat  in  the 
vagina,  pain  in  the  pelvis,  and  sometunes  vesical  and  rectal  irrita- 
bility. 


GONORRHCEAL  VAGINITIS.  83 

The  objective  symptoms  are  a  muco-pumlent  vaginal  discharge 
which  may  irritate  the  vulva ;  the  vagina  appears  red,  perhaps  gran 
ular  or  cystic  in  places. 

The  chronic  form  resembles  the  acute  except  in  degree  ;  in  it  the 
subjective  symptoms,  save  itching  caused  by  the  leucorrhoea,  are 
usually  absent. 

"What  is  the  treatment  of  simple  catarrhal  vaginitis  ? 

In  the  early  stages,  keep  the  patient  quiet ;  keep  the  bowels  open, 
and  give  light  diet ;  keep  the  urine  bland  by  alkaline  diluents.  If 
the  itching  is  severe,  let  the  patient  take  frequent  warm  alkaline 
sitz-baths;  in  addition,  irrigation  of  the  vagina  with  warm  water 
containing  either  of  the  following  will  be  found  of  value :  Liquor 
plumbi  subacet.  3j-0j ;  borax  5j-0j. 

After  irrigation  it  is  well  to  dust  some  desiccating  powder,  like 
bismuth,  upon  the  vulva. 

When  the  vaginitis  becomes  subacute  or  chronic,  make  applica- 
tion to  the  vagina  of  nitrate  of  silver  gr.  x-xxx-5j,  or  pyrohgneous 
acid. 

Let  the  patient  use  daily  vaginal  douches  of  hot  water  containing 
borax,  3j-0j ;  or  sulphate  of  zinc,  5ss-5j-0j ;  or  alum,  5j-0j. 

The  douches  should  be  taken  while  the  patient  is  in  the  dorsal 
position,  not  sitting. 


Gonorrhceal  Vaginitis. 

How  does  gonorrhceal  vaginitis  differ  from  the  simple  catar- 
rhal? 

a.  The  onset  is  usually  more  acute. 

h.  The  discharge  is  more  purulent,  viscid  and  offensive  than  in 
the  simple  catarrhal. 

c.  Urethritis  is  more  common. 

d.  Sometimes  a  history  of   exposure  to  infection  can  be  ob- 
tained. 

e.  Often  gonorrhoea!  warts  or  buboes  are  present. 

/.  The  most  certain  diagnostic  point  is  the  presence  of  gonococcl 


84  ESSENTIALS   OF  GYNECOLOGY. 

What  are  the  frequent  complications  and  results  of  gonor- 
rhoeal  vaginitis  ? 

Vulvitis,  urethritis,  endometritis,  salpingitis,  ovaritis  and  perito- 
nitis. 

The  dangers  of  gonorrhceal  vaginitis  have  been  greatly  under- 
estimated. 

"What  is  the  treatment  of  gonorrhceal  vaginitis  ? 

Keep  the  patient  quiet ;  attend  to  diet ;  move  the  bowels  with 
salines ;  keep  urine  bland.  During  the  acute  stage,  let  the  patient 
have  bichloride  vaginal  douches,  1-10,000,  three  or  four  times  a  day. 
After  the  acute  stage  has  passed,  thoroughly  disinfect  the  vagina 
with  bichloride,  1-1000,  and  loosely  pack  the  vagina  with  sterile 
gauze  to  keep  the  walls  separated  and  the  labia  apart,  thus  insuring 
drainage.  Repeat  this  process  every  24  hours  until  the  disease  has 
subsided. 

If  the  condition  tends  to  become  chronic,  apply  nitrate  of  silver, 
gr.  xx-xxx-^j,  two  or  three  times  a  week,  letting  the  patient  use 
daily  douches  of  borax  water. 

The  complicating  vulvitis  requires  its  own  treatment. 


Ulcerative  Vaginitis. 

Describe. 

Ulcerative,  senile  or  adhesive  vaginitis  is  present  to  a  greater  or 
less  extent  in  nearly  every  woman  over  60.  It  may  occur  earlier  in 
life. 

There  is  a  desquamation  of  the  squamous  epithelium  in  spots,  and 
where  these  raw  areas  lie  in  apposition,  adhesion  is  apt  to  occur. 
There  is  usually  a  thin  leucorrhoea,  which  irritates  the  vulva  and 
causes  pruritis. 

What  is  the  treatment  ? 

The  treatment  consists  in  the  application  to  the  vagina  of  such 
solutions  as  nitrate  of  silver,  gr.  x-xx-^j,  or  pyroligneous  acid,  and 
the  use  by  the  patient  of  astringent  vaginal  douches,  such  as  sul- 
phate of  zinc  ,^ss-Oj,  alum  5j-0j,  or  borax  5j-0j. 


PELVIC  PERITONEUM. 


85 


Diphtheritic  Vaginitis. 

What  is  the  etiology  and  treatment  ? 

Diphtheritic  vaginitis  is  aa  expression  of  constitutional  diphtheria, 
with  its  regular  etiology  and  symptoms. 

The  treatment  should  consist  of  local  antiseptics  and  the  con- 
stitutional treatment  for  diphtheria. 

Pelvic  Peritoneum. 

Describe. 

The  pelvic  peritoneum  is  a  continuation  of  that  hning  the  inner 
surface  of  the  walls  of  the  abdomen ;  it  covers,  more  or  less  com- 
pletely, the  pelvic  organs  (the  ovary  is  regarded  as  not  covered  by 
peritoneum),  lines  the  pelvic  walls  and  also  the  floor  of  the  pelvis. 
Traced  from  before  backward,  in  the  median  line,  it  leaves  the 
anterior  abdominal  wall  about  IJ  inches  above  the  symphysis,  is 
reflected  over  the  fundus  of  the  bladder  and  down  its  posterior 
surface  to  about  the  level  of  the  internal  os ;  it  then  passes  over 
to  the  uterus,  covers  its  anterior  surface  above  that  point,  passes 
over  the  fnndus  and  down  its  posterior  surface  to  the  vaginal 
junction,  thence  down  the  vaginal  wall  for  about  an  inch  ;  it  then 
passes  to  the  rectum,  covers  the  anterior  surface  of  the  middle 
portion,  and  surrounds  the  upper  portion  completely.  The  pelvic 
peritoneum  is  thrown  into  several  folds  and  forms  several  pouches. 

Describe  the  folds  and  pouches  of  the  pelvic  peritoneum. 

The  principal  folds  are  the  broad,  utero-vesical  and  utero-sacral 
ligaments  (so-called).  The  broad  ligaments,  extending  from  the 
sides  of  the  uterus  to  the  sides  of  the  pelvis,  in  front  of  the 
sacro  iliac  synchondrosis,  divide  it  into  two  fossae,  the  anterior  and 
posterior  ;  these  are  also  subdivided,  the  anterior  by  the  utero- 
vesical  ligaments,  the  posterior  by  the  utero-sacral.  The  pouch 
between  the  utero-vesical  ligaments  is  called  the  utero-vesical  pouch ; 
that  between  the  utero-sacral,  the  pouch  of  Douglas,  which  is  the 
deepest  part  of  the  peritoneal  cavity. 

The  pouches  between  the  utero-vesical  and  broad  ligaments  are 
called  the  para-vesical  pouches  ;  those  between  the  utero-sacral  and 
broad  ligaments  are  called  by  P<-)lk  the  "retro-ovarian  shelves." 


86  ESSENTIALS   OF  GYNECOLOGY. 

Two  other  pouches  are  raentioned,  which  depend  on  the  condition 
of  the  bladder  :  the  vesico-abdominal,  when  the  bladder  is  distended ; 
and  the  utero-abdominal,  when  the  bladder  is  empty  and  contracted. 

What  are  the  boundaries  of  the  utero-vesical  pouch  ? 

It  is  bounded  in  front  by  the  posterior  surface  of  the  bladder, 
behind  by  the  anterior  surface  of  the  uterus,  and  laterally  by  the 
utero  vesical  ligaments. 

What  are  the  boundaries  of  the  pouch  of  Douglas  ? 

It  is  bounded  in  front  by  the  posterior  surface  of  the  uterus  and 
the  upper  portion  of  the  posterior  vaginal  wall,  behind  by  the  rec- 
tum, and  laterally  by  the  utero-sacral  ligaments. 

What  are  the  boundaries  of  the  retro-ovarian  shelves  ? 

They  are  triangular  in  shape,  bounded  in  front  by  the  base  of  the 
broad  ligament,  internally  by  the  utero-sacral  ligament,  and  exter- 
nally by  the  wall  of  the  pelvis. 


Pelvic  Peritonitis. 

What  is  the  pathology  ? 

The  peritoneum  first  becomes  hyperaemic  ;  it  loses  its  lustre,  and 
exudation  materials  are  poured  out. 

1.  There  may  be  scarcely  any  serum  exuded  ;  the  inflamed  area 
is  coated  with  fibrin,  and  adhesions  form,  binding  together  the  pelvic 
organs  and  intestines. 

2.  The  exudation  may  consist  largely  of  serum,  either  free  in  the 
peritoneal  cavity,  or  encapsulated  by  adhesions. 

3.  The  exudation  in  severe,  especially  septic  cases  is  often  puru- 
lent. 

Hence  the  varieties  : — ■ 

a.  Adhesive. 
h.   Serous. 
d.  Purulent. 

What  is  the  etiology  ? 

In  a  general  way,  the  etiology  of  pelvic  peritonitis  may  be  stated 
as  an  extension  to  the  peritoneum  of  inflammation  of  the  uterus, 


PELVIC   PERITONITIS.  87 

ovaries  or  tubes  ;  in  a  large  majority  of  the  cases,  inflammation  of 
the  tubes. 

There  is,  usually,  first  an  endometritis,  then  a  salpingitis,  and 
then  a  peritonitis. 

Individual  causes  are  as  follows  : — 

a.  Introduction  of  sepsis  during  parturition,  abortion  or  opera- 
tions. 

h.  Gonorrhoea. 

c.  Introduction  into  the  uterus  of  septic  instruments. 

d.  Injection  of  fluids  through  uterus  and  tubes  into  the  peritoneal 
cavity. 

e.  Catching  cold  during  menstruation. 

/.  Tubercular  or  cancerous  disease  of  the  pelvic  organs. 
g.  Tumors  causing  irritation  of  the  peritoneum. 
h.  Pelvic  cellulitis  and  peritonitis  are  often  associated  as  being 
produced  by  the  same  causes. 

What  are  the  symptoms  ? 

Pelvic  peritonitis  may  be  either  acute  or  chronic. 

Acute  pelvic  peritonitis  is  usually  ushered  in  by  a  rigor;  this, 
however,  is  not  always  present.  There  are  pain  and  tenderness  in  the 
lower  part  of  the  abdomen  ;  patient  lies  on  the  back,  with  the  knees 
elevated ;  the  pulse  is  small,  wiry  and  rapid ;  the  temperature  is 
elevated,  101°-103°,  sometimes  higher;  nausea  and  vomiting  are  com- 
mon ;  more  or  less  tympanites  is  present ;  the  bowels  are  constipated ; 
there  is  frequently  irritability  of  the  bladder;  often  menorrhagia. 

Chronic  peritonitis  may  exist  and  present  scarcely  any  symptoms 
save  a  dull  pain  in  the  pelvis  ;  usually,  there  is  vesical  and  rectal 
irritability,  dyspareunia,  leucorrhcea,  and  a  disturbance  of  menstrua- 
tion, especially  menorrhagia. 

Chronic  peritonitis  may  follow  the  acute,  or  may  begin  as  chronic. 

Pelvic  peritonitis  is  often  characterized  by  exacerbations. 

What  are  the  physical  signs  of  acute  pelvic  peritonitis  ? 

The  vagina  is  hot  and  dry ;  pressure  in  either  fornix,  or  on  the 
abdomen,  is  intensely  painful ;  the  bimanual  is  impracticable ;  the 
uterus,  tubes  and  ovaries  are  usually  bound  fast ;  the  slightest 
attempt  to  move  them  causes  intense  pain.  The  fornices  may  seem 
to  be  covered  by  a  hard,  flat  roof,  formed  by  a  matting  together  of 


88  ESSENTIALS   OF   GYNECOLOGY. 

the  pelvic  contents,  often  compared  to  plaster-of-Paris  poured  into 
the  pelvis  and  hardened  ;  you  may  feel  a  tumor  close  to  the  uterus, 
consisting  of  serum  or  pus,  roofed  in  by  adhesions  ;  the  most  com- 
mon situation  of  this  tumor  is  in  the  pouch  of  Douglas. 

What  are  the  common  results  of  pelvic  peritonitis  ? 

Displacement  of  uterus,  ovaries  and  tubes,  the  tubes  being  often 
distorted  and  stenosed  by  the  traction  of  adhesions  ;  as  a  result  of 
these  conditions  we  get  disturbances  of  menstruation,  sterility  and 
ectopic  gestation. 

What  is  the  prognosis  of  pelvic  peritonitis  ? 

Simple  adhesive  peritonitis  often  ends  in  complete  recovery  ;  dis- 
placement of  the  pelvic  organs  may  remain,  however,  and  give  rise 
to  symptoms.     The  prognosis  of  purulent  peritonitis  is  grave. 

What  is  the  treatment  of  pelvic  peritonitis  ? 

In  the  acute  form,  keep  the  patient  quiet  in  bed,  give  fluid  diet, 
apply  cold  to  the  lower  portion  of  the  abdomen,  either  in  the  form 
of  the  ice-bag  or  cold-water  coil.  In  some  cases  hot  appHcations 
are  more  grateful  to  the  patient ;  if  there  is  great  pain,  give  a  little 
morphine  ;  after  a  few  days,  move  the  bowels  gently,  as  by  calomel 
gr,  j  every  hour  for  3-4  doses,  assisted,  if  necessary,  by  an  enema. 
After  the  acute  stage  has  passed,  and  in  chronic  cases,  use  iodine 
externally  and  per  vaginam,  and  vaginal  tampons  of  boroglyceride 
or  ichthyol  and  glycerine.  A  wet  towel,  covered  by  a  dry  one  or  a 
protective,  worn  about  the  pelvis  at  night,  is  sometimes  of  value 
in  chronic  peritonitis.  Look  after  the  general  health  by  attention 
to  fresh  air,  administering  tonics,  and  regulating  the  bowels. 


Pelvic  Cellulitis. 

What  are  the  principal  situations  of  the  cellular  tissue  in  the 
pelvis  ? 

1.  Between  the  abdominal  wall  and  peritoneum,  behind  the  pubes, 

2.  In  front  of  and  behind  the  cervix. 

3.  In  the  broad  ligaments. 

4.  In  the  utero-sacral  ligaments. 


PELVIC   CELLULITIS.  89 

What  is  the  etiology  of  pelvic  cellulitis  ? 

The  etiology  of  pelvic  cellulitis  may  almost  invariably  be  summed 
up  in  two  words— traumatism  and  sepsis  ;  the  traumatism  being, 
usually,  labor,  abortion,  or  operations  on  the  cervix. 

Pelvic  cellulitis  was  formerly  considered  very  common,  but  in  the 
light  of  recent  experience,  gained  by  laparotomies,  the  "masses," 
"thickenings,"  etc.,  are  most  often  found  to  be  salpingitis  and 
peritonitis. 

In  other  words,  pelvic  cellulitis,  although  it  does  exist,  is  com- 
paratively infrequent. 

What  is  the  pathology? 

There  is  an  exudation  of  serum,  fibrin  and  white  cells  ;  this  may 
resolve,  it  may  form  new  connective  tissue,  cicatricial  tissue,  or  it 
may,  and  often  does,  suppurate.  If  suppuration  occurs,  the  pus 
may  point  above  the  pubes  ;  this  is  especially  common  in  puerperal 
cases.  It  frequently  ruptures  into  the  vagina,  bladder  or  rectum, 
sometimes  into  the  uterus  ;  it  occasionally  makes  its  way  through 
the  sciatic  or  obturator  foramen  ;  rarely,  it  ruptures  into  the  peri- 
toneal cavity. 

What  are  the  symptoms  of  pelvic  cellulitis  ? 

The  disease  is  usually  ushered  in  by  a  rigor,  which  is  often  marked ; 
the  temperature  rises,  103°-105°  ;  the  pulse  is  full  and  rapid  ;  the 
pain  is  not  very  acute  ;  nausea  is  occasionally  present ;  vomiting  is 
usually  absent,  unless  peritonitis  is  a  complication.  If  pus  forms, 
septic  symptoms  become  pronounced.  There  is  often  irritability  of 
bladder  and  rectum. 

Chronic  cases  may  present  few  symptoms  save  a  feeling  of  weight 
in  the  pelvis,  irritability  of  bladder  and  rectum,  and  menorrhagia. 

What  are  the  physical  signs  ? 

Usually,  there  is  a  tense,  elastic  tumor  bulging  into  the  vagina, 
most  commonly  on  the  left  side,  pushing  uterus  over  to  the  right ; 
it  is  sensitive,  but  not  acutely  so.  Sometimes  the  inflammatory 
process  involves  nearly  all  the  connective  tissue  of  the  pelvis,  and  the 
exudation  can  be  felt  in  the  iliac  fossae  and  above  the  pubes.  When 
pus  forms  you  have  the  physical  sig-r»«  of  an  abscess — tenderness, 
fluctuation,  etc. 


90  ESSENTIALS  OF  GYNECOLOGY. 

From  what  should  you  differentiate  pelvic  cellulitis  ? 

From —  a.  Pelvic  peritonitis. 

h.  Pelvic  liaematocele. 

c.  Fibroid  tumor  of  uterus. 

d.  Impaction  of  faeces. 

e.  Ovarian  tumor. 
/  Salpingitis. 

How  would  you  differentiate  pelvic  cellulitis  from  pelvic 
peritonitis  ? 

In  many  cases  it  is  almost  impossible  to  differentiate  the  two ; 
they  frequently  complicate  each  other.  The  chief  points  of  difference 
are  these  :  Pelvic  celluhtis  almost  never  occurs  except  after  labor, 
abortion,  or  operation  on  the  cervix  ;  pelvic  peritonitis  may  arise 
from  any  cause  of  inflammation  of  the  uterus  or  its  adnexa,  which 
may  extend  to  the  peritoneum.  Pain  and  tenderness,  as  a  rule, 
are  less  marked  in  cellulitis  than  in  peritonitis.  Cellulitis  is  more 
apt  to  bulge  into  the  vagina  than  is  peritonitis.  Cellulitic  deposits 
are  more  apt  to  suppurate  than  are  peritonitic.  Vomiting  is  less 
frequent  in  cellulitis  than  in  peritonitis. 

How  would  you  differentiate  pelvic  cellulitis  from  pelvic 
hsematocele  ? 

Chiefly  by  the  history  of  an  haematocele,  i.  e.,  sudden  sharp  pain, 
pallor,  faintness,  and  the  physical  signs  of  a  collection  of  fluid  which 
afterward  coagulates  and  hardens.  The  above  symptoms  of  shock 
and  hemorrhage  are  wanting  in  cellulitis. 

How  would  you  differentiate  cellulitic  or  peritonitic  deposits 
from  fibroids  of  the  uterus  ? 

Cellulitic  or  peritonitic  deposits    vs.  Fibroid  tumors. 

History  of  acute  inflammation.  Slow  growth. 

Pain  and  tenderness.            '  Insensitive. 

Less  plainly  outlined.  Outlines  more  distinct. 

Less  intimately  connected  with  Closely     connected     with     the 

the  uterus.  uterus. 

Perhaps  menorrhagia  during  the  Usually  menorrhagia,   gradually 

acute    stage,    then    irregular  increasing  till  the  menopause. 

menstruation. 


PELVIC  CELLULITIS.  -  91 

How  would  you  differentiate  impaction  of  faeces  from  pelvic 
peritonitis  or  cellulitis  ? 

In  impaction  of  faeces,  tlie  mass  is  sausage-shaped,  has  a  doaghy 
feel,  is  situated  in  the  position  of  the  rectuni;  and  is  less  closely  con- 
nected with  the  uterus  than  an  exudation  of  peritonitis  or  cellulitis ; 
it  is  not  as  tender  on  pressure,  and  gives  no  historj^  of  acute  inflam- 
mation.    The  diagnosis  is  made  certain  by  clearing  out  the  rectum. 

How  would  you  differentiate  a  small  ovarian  tumor  from 
pelvic  peritonitis  or  cellulitis  ? 

There  are  no  signs  of  acute  inflammation  as  in  cellulitis  or  perito- 
nitis ;  the  ovarian  cyst  is  usually  fluctuating  ;  its  multilocular  char- 
acter can  sometimes  he  felt.  The  menstrual  disturbances  common 
in  peritonitis  and  cellulitis  are  usually  absent  in  cases  of  ovarian  cysts ; 
an  ovarian  cyst  gradually  increases  in  size. 

How  would  you  differentiate  pelvic  cellulitis  from  salpin- 
gitis ? 

By  a  careful  bimanual,  in  a  case  of  salpingitis,  you  can  generally 
map  out  an  enlarged,  tortuous  tube,  usually  distended,  extending 
from  the  side  of  the  uterus  to  the  region  of  the  ovary  ;  if  distended 
with  fluid,  you  may  detect  fluctuation.  It  does  not  bulge  into  ths 
vagina  as  does  cellulitis. 

The  history  of  the  case  is  of  value  in  the  diagnosis. 

What  is  the  treatment  of  pelvic  cellulitis  ? 

1.  Prophylactic  : — 

Strict  cleanliness  and  antiseptic  precautions  during  labor,  abortion, 
operations,  etc. 

2.  Abortive  : — 

Put  patient  to  bed,  apply  cold  to  the  lower  portion  of  abdomen. 

3.  When  exudation  has  occurred  : — 

Apply  heat  to  the  abdomen,  administer  hot-water  vaginal  douches, 
move  bowels,  and  attend  to  the  general  health. 

4.  If  the  exudation  suppurates: — 

As  soon  as  pus  is  detected,  incise  under  antiseptic  precautions  and 
drain.  The  two  most  favorable  sites  for  incision  are  through  the 
vagina  and  through  the  abdominal  wall  just  above  Poupart's  liga- 
ment.    In  doubtful  cases  it  is  sometimes  advisable  to  open  the 


92  ESSENTIALS   OF  GYNECOLOGY. 

abdomen  in  the  median  line,  and  then  determine  by  the  relations 
of  the  mass,  the  best  mode  of  procedure.  This,  however,  is  rarely 
necessary. 

Pelvic  Hsematocele  and  Haematoma. 

Befine,  and  give  the  pathology. 

Pelvic  hsematocele  is  an  effusion  of  blood  into  the  cavity  of  the 
pelvic  peritoneum. 

Pelvic  haematoma  is  an  effusion  of  blood  into  the  connective  tis- 
sue of  the  pelvis  beneath  the  peritoneum,  usually  between  the  folds 
of  the  broad  ligaments. 

In  a  pelvic  haematocele,  the  effusion  is  usually  into  the  pouch  of 
Douglas ;  if  this  is  closed  by  adhesions,  or  if  the  efi"usion  is  very 
large,  the  blood  may  flow  over  into  the  utero-vesical  pouch.  The 
former  condition  gives  rise  to  the  name  retro-uterine,  the  latter  to 
ante-uterine  haematocele.  The  blood  is  at  first  fluid  ;  it  then  slowly 
coagulates  and  is  roofed  in  by  peritonitic  exudate  binding  together 
adjacent  structures : — coils  of  intestine,  omentum,  uterus,  etc.  This 
blood  mass,  if  small,  may  be  absorbed ;  usually,  however,  it  is  due 
to  a  ruptured  ectopic  gestation  sac  or  a  tubal  abortion  and  under 
these  circumstances  recurrent  hemorrhages  into  the  mass,  sufficient 
to  burst  its  limiting  wall  are  common.  Occasionally,  apparently 
from  proximity  to  the  intestine,  it  suppurates. 

What  is  the  etiology  of  pelvic  haematocele  ? 

Formerly  long  hsts  of  causes  were  given  for  this  condition.  We 
now  know  that  in  most  cases  it  is  due  to  a  ruptured  ectopic  gesta- 
tion sac  or  a  tubal  abortion.  It  is  probable  that  exceptions  to  this 
rule  occasionally  occur,  such  as — 

Rupture  from  traumatism  of  vascular  peritonitic  adhesions. 

Oozing  after  removal  of  diseased  tubes  and  ovaries. 

Excessive  haemorrhage  from  the  rupture  of  a  Graafian  follicle. 

Rupture  of  an  ovarian  haematoma. 

What  is  the  etiology  of  pelvic  haematoma  ? 

Here  again  a  rupture  of  an  ectopic  gestntion  sac  is  a  very  com- 
mon cause.  Other  causes,  however,  are  probably  more  frequent 
than  in  the  case  of  pelvic  haematocele,  for  varix  of  the  broad  liga- 
ment, due  to  various  causes  of  venous  congestion  is  common,  and 


PELVIC   HEMATOCELE  AND   HEMATOMA.  93 

when  such  a  varix  exists,  but  a  slight  traumatism  is  needed  for  a 

blood  effusion. 

What  are  the  symptoms  of  pelvic  haematocele  ? 

A  sudden  sharp  pain,  and  symptoms  of  shock  and  hemorrhage. 
The  face  becomes  pallid,  the  expression  anxious  ;  the  pulse  is  rapid 
and  feeble ;  temperature  subnormal ;  surface  covered  with  a  cold 
perspiration :  perhaps  nausea  and  vomiting.  Later  if  the  patient 
survive,  we  have  symptoms  of  peritonitis  and  of  pressure,  either 
from  the  effusion  or  the  displaced  uterus.  The  pain  and  tenderness 
continue  for  several  days ;  there  is  usually  painful  defecation  and 
dysuria ;  usually  metrorrhagia  is  present.  In  a  few  days,  if  sup- 
puration does  not  occur,  the  effusion  diminishes  in  size  and  the 
symptoms  abate.     If  suppuration  occurs,  septic  symptoms  appear. 

The  above  are  the  symptoms  of  a  well-marked  case ;  where  the 
effusion  is  small  the  symptoms  may  be  much  less  severe. 
How  do  the  symptoms  of  pelvic  haematoma  compare  with 
those  of  pelvic  hsematocele  ? 

In  pelvic  haematoma  there  is,  as  a  rule,  less  pain  and  less  shock. 
If  the  effusion  is  large,  however,  there  may  be  the  symptoms  of 
shock  and  hemorrhage. 
What  are  the  physical  signs  of  pelvic  haematocele  ? 

At  first  no  tumor  is  felt ;  only  an  indistinct  sensation  of  fulness 
in  the  pouch  of  Douglas ;  as  the  blood  coagulates  and  is  roofed  in 
by  adhesions,  one  can  feel  a  boggy  tumor  bulging  downward  in  the 
posterior  vaginal  fornix  and  pushing  the  uterus  forward. 

What  are  the  physical  signs  of  pelvic  hsematoma  ? 

In  this  case  there  is  felt  a  distinct  tumor  even  at  first ;  it  bulges 
down  on  one  side  of  and  behind  the  cervix ;  pushes  the  uterus  for- 
ward and  to  the  opposite  side ;  seems  attached  to  the  side  of  the 
pelvis  and  can  be  felt  above  Poupart's  ligament  when  it  has  opened 
out  the  folds  of  the  broad  ligament  and  lifted  up  the  peritoneum 
from  the  pelvis.  A  finger  introduced  into  the  rectum  will  usually 
detect  a  stricture. 

What  is  the  prognosis  of  pelvic  haematocele  ? 

The  prognosis  is  usually  that  of  ruptured  ectopic  gestation  and 
will  be  discussed  under  that  condition. 


94 


ESSENTIALS   OF  GYNECOLOGY. 


What  is  the  prognosis  of  pelvic  hsematoma  ? 

Usually  good.  If  the  effusion  suppurates,  the  prognosis  is  less 
favorable.  It  may  rupture  into  rectum,  vagina,  bladder,  or  rarely 
above  the  pelvic  brim. 

How  would  you  differentiate  pelvic  haematocele  from  acute 
pelvic  peritonitis  ? 


Pelvic  hcematocele 

History  of  sudden,  sharp  pain, 
with  symptoms  of  shock  and 
hemorrhage. 

Absence  of  acute  inflammation 
at  first. 

Uterus  ::isually  displaced  for- 
ward. 


vs.-        Acute  pelvic  peritonitis. 

Less  sudden  in  onset ;  symptoms 
of  shock  and  hemorrhage 
wanting. 

Symptoms  of  acute  inflammation 
at  first. 

Utems  fixed,  not  markedly  dis- 
placed. 


How  would  you  differentiate  pelvic  haematocele  from  a  fibroid 
tumor  of  the  uterus  ? 


Pelvic  hcematocele 

History  of  sudden,  sharp  pain 
and  symptoms  of  shock  and 
hemorrhage. 

Soon  followed  by  signs  of  in- 
flammation. 

Less  intimately  connected  with 
the  uterus. 

Sensitive  to  pressure. 

Density  less. 


vs.  Fibroid  tumor. 

Of  slow  growth ;  symptoms 
gradually  developed.  - 

Absence  of  signs  of  inflamma- 
tion. 

More  intimately  connected  with 
the  uterus  ;  moves  with  it. 

Insensitive  to  pressure. 

Density  greater. 


How  would  you  differentiate  pelvic  haematocele  from  a  retro- 
flexed  or  retroverted  uterus  ? 

Pelvic  Twematocele  vs.  Retrojiexed  or  retroverted  uterus. 

Acute  history  of  pain,  shock  and      Usually  a  long  history. 

hemorrhage. 
Fundus  of  uterus  usually  lies      Fundus    backward ;     absent    in 

forward.  front. 

Sensitive  to  pressure.  Less  sensitive,  unless  surrounded 

by  peritonitis. 


PELVIC  HEMATOCELE  AND   HEMATOMA.  95 

How  would  you  differentiate  pelvic  haematocele  from  an 
ovarian  cyst  ? 

Pelvic  hcematocele  vs.  Ovarian  cyst. 

Acute  history  of  pain,  shock  and      History  of  slow  growth,  with  few 

hemorrhage.  general  symptoms. 

More  sensitive  to  pressure.  Less  sensitive  to  pressure. 

First  elastic  and  soft,  then  hard.      Usually  fluctuating  throughout. 

• 

How  would  you  differentiate  pelvic  haematocele  from  im- 
pacted faeces  ? 

By  the  history,  rectal  examination,  and  thorough  emptying  of  the 
rectum. 

How  would  you  differentiate  pelvic  haematocele  from  retro- 
uterine carcinoma  ? 

Pelvic  hcematocele  vs.       Retro^uterine  carcinoma. 

Acute  history  of  pain,  shock  and      History  of  a  chronic  disease. 

hemorrhage. 
Uterus  usually  pushed  forward.      Uterus  but  little  displaced. 

How  would  you  differentiate  pelvic  haematoma  from  pelvic 
cellulitis  ? 

Pelvic  hematoma              vs.  Pelvic  cellulitis. 

History  of  sudden,  sharp  pain.  History  of  labor,    abortion,    or 

perhaps  symptoms  of   shock  operation  on  the  cervix. 

and  hemorrhage. 

Signs  of  acute  inflammation  ab-  Signs    of    acute    inflammation 

sent  at  first.  from  the  first. 

Less  sensitive.  More  sensitive. 

What  is  the  treatment  of  pelvic  haematoma  ? 

Keep  the  patient  quiet  in  bed :  at  first  ajDply  cold,  later  heat, 
both  externally  in  the  form  of  poultices  and  per  vaginani  by  hot 
water  douches.  If  suppuration  occurs,  open  and  drain  through 
the  vagina.  If  repeated  hemorrhages  are  added  to  this  haematoma 
two  courses  are  open  according  to  the  size  of  the  tumor.  If  the 
tumor  is  small  and  low  in  the  pelvis,  incise  through  the  vagina, 
clean  out  clots,  etc.,  and  drain.  If  the  tumor  is  large  and  extends 
high  in  the  pelvis,  it  is  probably  better  to  open  the  abdomen  and 
govern  the  treatment  by  the  condition  found. 


96  ESSENTIALS   OF   GYNAECOLOGY. 

The  treatment  of  pelvic  haematocele  will  be  considered  under 
ectopic  gestation. 


MENSTRUATION. 

Define. 

Menstruation  is  a  periodical  series  of  phenomena,  the  most  marked 
of  which  is  a  discharge  of  blood  from  the  uterine  mucous  membrane, 
with  a  shedding  of  its  superficial  layers,  beginning,  on  an  average,  in 
this  country,  at  fourteen,  and  recurring  monthly  till  forty-five.  The 
relation  of  menstruation  to  ovulation  is  still  unsettled  ;  Lawson  Tait 
claiming  that  the  Fallopian  tubes  have  more  influence  on  menstrua- 
tion than  have  the  ovaries. 

Describe  the  factors  which  influence  the  onset  of  menstrua- 
tion ;  what  is  the  average  frequency  and  duration  of 
each  period  ? 

In  temperate  climates,  menstruation  usually  appears  at  13-15 
years  ;  it  is  earlier  in  warmer  climates,  later  in  cooler  ;  it  appears  in 
ghls  who  live  an  indoor,  city  life,  earlier  than  in  the  country.  The 
periods  nonnally  appear  every  28  days,  but  in  this  there  are  great 
variations ;  some  women  in  perfect  health  menstruate  every  3  weeks, 
some  only  every  5  weeks. 

The  average  duration  of  each  period  is  3-4  days,  but  this  varies 
between  2  and  8.  The  discharge  of  blood  is  usually  slight  at  first, 
reaches  maximum  on  the  second  or  third  day,  then  gradually  dimin- 
ishes. 

Disorders  of  Menstruation. 

Amenorrhcea. 

Define.  — *■"• """^ 


Amenorrhoea  is  the  absence  of  menstruation  between  puberty  and 
the  menopause.  It  is  the  normal  condition  during  pregnancy  and 
lactation.     It  may  be  divided  into  : — 

a.  Emansio  mensium — 

Where  menstruation  has  never  appeared. 
h.  Suppresio  mensium — 

Where  menstruation  has  appeared,  but  fails  to  reappear. 


MENSTRUATION — AMENORRHCEA.  97 

What  iis  the  etiology  of  amenorrhcea  ? 

The  most  frequent  cause  is  angemia,  especially  that  form  called 
chlorosis.  Other  causes  are  phthisis,  or  other  debilitating  diseases  ; 
acute  diseases  at  puberty ;  non-development  of  the  generative  organs ; 
atrophy  of  the  generative  organs ;  increasing  obesity ;  removal  of 
ovaries  and  tubes  by  operation. 

What  are  the  symptoms  ? 

Amenorrhoea  is  itself  more  a  symptom  than  a  disease,  and  the 
symptoms  which  usually  accompany  amenorrhoea  are  those  of  the 
disease  which  causes  it — most  frequently  anaemia  or  phthisis.  Thus, 
from  anaemia  we  have : — 

PaUor. 

Dyspnoea  and  palpitation  of  the  heart  on  exertion. 

Depraved  appetite. 

Constipation. 

Headache. 

(Edema. 

Murmur  at  the  base  of  the  heart. 

Neuralgic  pains. 

Hysteria. 
From  phthisis  we  get  the  regular  symptoms  of  cough,  emaciation 
and  night  sweats. 

What  is  the  prognosis  ? 

When  associated  with  simple  anaemia  the  prognosis  is  good. 
When  due  to  non-development  of  the  generative  organs  the  amen- 
orrhoea usually  continues.  When  associated  with  phthisis  or  other 
wasting  disease,  the  prognosis  is  that  of  the  disease. 

What  is  the  treatment  of  amenorrhcea  ? 

a.  When  due  to  anaemia  : — 

Some  form  of  iron,  as  Blaud's  pills;  oxygen;  nourishing  food; 
fresh  air ;  regulation  of  the  bowels,  and  attention  to  the  mode  of 
life.  Permanganate  of  potash  and  the  black  oxide  of  manganese 
are  recommended,  but  their  usefulness  is  doubted  by  many. 

h.  When  due  to  imperfect,  or  non-development  of  the  generative 
organs : — 

Determine,  under  anaesthesia,  whether  ovaries  are  present  or  not ; 
if  absent,  do  not  attempt  to  induce  menstruation.  If  the  ovaries  are 
7 


98  ESSENTIALS   OF  GYNECOLOGY. 

present,  besides  attention  to  tlie  general  health,  the  following  methods 
may  be  employed  : — 

Hot  water  vaginal  douches  ; 

Boro-glyceride  tampons  ; 

Electricity  to  uterus  and  over  ovaries. 
c.  When  associated  with  phthisis,  or  other  wasting  disease,  the 
treatment  is  that  of  the  associated  disease. 

In  cases  of  acute  suppressio-mensium,  due  to  exposure  to  cold, 
etc. ,  hot  mustard  foot  baths,  hot  applications  to  the  pelvic  region 
and  diaphoretics  internally,  may  be  used  with  safety  and  advantage. 

Vicarious  Menstruation. 
Describe. 

Vicarious  menstruation  is  a  periodical  discharge  of  blood  from 
some  part  of  the  body  other  than  the  interior  of  the  uterus.  It  may 
occur  with  either  amenorrhoea  or  scanty  menstruation ;  it  usually 
appears  at  about  the  time  of  the  regular  flow.  It  may  come  from 
almost  any  mucous  membrane :  from  the  nose,  mouth,  etc.  ;  it  may 
also  come  from  the  nipple  or  from  an  open  sore ;  it  is  usually  due  to 
a  watery  condition  of  the  blood  and  a  poor  condition  of  the  blood- 
vessels.    Direct  treatment  is  usually  not  required. 

Menorrhagia  and  Metrorrhagia^ 

Define.        —^^ ■ 

Menorrhagia  is  a  prolonged  or  excessive  menstrual  flow. 
Metrorrhagia  is  "uterine  hemorrhage  occurring  independently  of 
the  menses. " 

What  is  the  etiology? 

Menorrhagia  and  metrorrhagia  may  be  produced  by  causes  acting 
at  a  distance,  or  local,  in  or  about  the  uterus  itself.  Acting  at  a 
distance  are  : — 

1.  Obstructed  general  circulation  from  disease  of  heart,  lungs  or 
liver. 

2.  Low  condition  of  blood  and  vessels  in  certain  wasting  diseases. 
Acting  about  the  uterus  are  : — 

1.  Tumors. 

2.  Ectopic  Gestation. 

3.  Disease  of  tubes  or  ovaries. 


MENSTRUATION— DYSMENORRHEA.  99 

The  most  common  causes  are  situated  in  the  uterus  itself,  and 
among  them  are  the  following  : — ■ 

1.  Subinvolution  of  the  uterus  ; 

2.  Retained  secundines  ; 

3.  Submucous,  or  interstitial  fibroids  ; 

4.  Polypi ; 

5.  Carcinoma; 

6.  Fungous  granulations  of  the  endometrium. 
The  last  is  the  most  common  cause  of  all. 

What  is  the  treatment  of  menorrhag-ia  and  metrorrhagia  ? 

When  due  to  causes  acting  outside  of  the  uterus,  the  treatment  is 
that  of  these  causes ;  at  the  same  time,  there  will  often  be  found 
fungous  granulations  of  the  endometrium  which  magnify  the  influ- 
ence of  the  distant  causes ;  unless  otherwise  contraindicated,  these 
fungosities  need  to  be  removed  by  the  curette  under  antiseptic  pre- 
cautions ;  the  uterine  cavity  is  then  washed  out,  and  drained  with  a 
strip  of  iodoform  gauze  introduced  into  it,  or  an  application  of 
iodine  or  carbolic  acid  or  a  mixture  of  the  two  is  made  to  the  endo- 
metrium. In  mild  cases  of  menorrhagia  or  metrorrhagia  ergot  and 
hydrastis  canadensis  are  of  value  even  without  the  use  of  the 
curette,  and  in  nearly  all  except  malignant  cases  after  curetting.  Dis- 
eases of  the  tubes  and  ovaries  and  ectopic  gestation  require  their  own 
treatment.  Fibroids  may  demand  removal  of  the  tumor  or  hys- 
terectomy. Polypi  require  removal.  Carcinoma  indicates  hys- 
terectomy.    Fungous  endometritis  demands  curetting  as  above. 

Dysmenorrhoea. 
Define.  ".fc>v3^3..i.-^a_- 

Dysmenorrhoea  may  be  defined  as  the  occurrence  of  pain  jus( 
before,  during  or  after  the  menstrual  period  "  (Hart  ancT  Barbour). 

What  are  the  varieties  of  dysmenorrhoBa  ? 

The  following  varieties  are  mentioned,  but  seldom  distinctly 
differentiated  : — 

1.  Obstructive; 

2.  Congestive; 

3.  Neuralgic ; 

4.  Ovarian  ; 

5.  Membranous. 


100  essentials  of  gynecology. 

Obstructive  Dyssienorrhcea. 

What  is  the  etiology  ? 

Both  the  etiology  and  pathology  of  the  different  varieties  of 
dysmenorrhcea  are  still  far  from  settled,  but  the  conditions  usually 
associated  with  obstructive  dysmenorrhoea  are  : — 

a.  Flexions  of  the  uterus  ; 

h.  Stenosis  of  os  externum,  os  internum,  or  the  whole  cervical 
canal ; 

c.  Polypi ; 

d.  Fibroids  distorting  uterine  canal ; 

e.  Long,  conical  cervix  ; 

/.    Spasmodic  contraction  of  os  internum. 

What  are  the  symptoms  ? 

Intermittent,  cramp-like  pains,  accompanying  the  expulsion  of 
blood  clots  which  have  formed  above  the  obstruction ;  this  expulsion 
is  followed  by  relief  A  sound  passed  between  the  peiiods  usually 
shows  hyjDeraesthesia  of  the  internal  os. 

What  is  the  treatment  ? 

During  the  intermenstrual  period  dilate  the  cervical  canal  with 
one  of  the  dilators  of  the  glove-stretcher  variety.  If  there  seems 
to  be  any  endometritis  present,  curette  the  uterus  and  wash  it  out. 
Pack  the  cavity  with  iodoform  gauze,  and  unless  the  pain  is  severe 
leave  it  for  forty-eight  hours  ;  this  will  maintain  the  dilatation  for 
quite  a  period.  In  order  to  prevent  future  recontraction,  the  occa- 
sional introduction  of  graduated  sounds  is  of  value.  All  this  must 
be  done  under  strict  asepsis.  The  use  of  intra-uterine  stems  had 
better  be  abandoned.  For  the  temporary  relief  of  the  several  vari- 
eties of  dysmenorrhoea  the  preparations  of  viburnum  are  of  value. 

Congestive  Dysjnienorrhcea. 

What  is  the  etiology  ? 

"Congestive  dysmenorrhcea  depends  upon  an  advance  of  the 
menstmal  congestion  beyond  the  physiological  limits ' '  (Reeve). 

The  conditions  associated  with  congestive  dysmenorrhoea  are  the 
following : — 

a.  Exposure  to  cold  ; 

h.  Defective  general  circulation  ; 


MENSTRUATION — DYSMENORRHCEA.  101 

c.  Metritis ; 

d.  Endometritis ; 

e.  Displacements  of  tire  uterus  ; 
/.   Pelvic  tumors ; 

g.  Pelvic  peritonitis. 

What  are  the  symptoms  ? 

Between  tire  periods  there  are  usually  symptoms  of  pelvic  trouble, 
or  defective  general  circulation. 

Just  before  the  flow  begins,  there  appear  feehngs  of  weight  and 
heat  in  back  and  pelvis,  headache,  flushing  of  the  face,  and  some 
rise  of  temperature  ;  the  pulse  is  rapid.  The  symptoms  are  usually 
reheved  by  a  free  flow. 

What  is  the  treatment  ? 

a.  During  the  attack — 

1.  Hot  mustard  foot-baths ; 

2.  Hot  sitz -baths ; 

3.  Diaphoretics,  such  as  Dover's  powder; 

4.  Hot  pelvic  applications. 
h.  During  the  intermenstrual  periods — 

1.  Seek  to  remove  the  cause  ; 

2.  Scarify  cervix  occasionally  ; 

3.  Employ  glycerine  tampons  ; 

4.  Avoid  excessive  coitus  and  exertion. 
Just  before  the  flow  begins,  use  hot-water  vaginal  douches. 

Neuralgic  Dysmenorrhcea. 

What  is  the  etiology  ? 

This  frequently  occurs  in  combination  with  some  of  the  other 
forms  of  dysmenorrhoea,  especially  the  congestive  ;  it  is  most  often 
associated  with  an  indolent,  indoor  life,  anaemia,  malnutrition, 
chronic  malarial  disease  or  hysteria.  Sometimes  no  cause  can  be 
assigned. 

What  are  the  symptoms  ? 

Pain,  sometimes  referred  to  uterus,  sometimes  to  ovaries,  some- 
times elsewhere  ;  it  changes  its  situation  ;  is  often  shooting  in  char- 
acter ;  usually  begins  a  little  before  the  flow  ;  is  sometimes  relieved 


102  ESSENTIALS  OP  GYNECOLOGY. 

by  a  free  flow.  Between  the  periods,  no  pathological  changes  can 
be  detected  in  the  pelvic  organs,  but  patient  suffers  from  neuralgia 
elsewhere — facial,  intercostal,  etc. 

What  is  the  treatment? 

Attention  to  the  mode  of  life;  fresh  air;  exercise;  tonics,  espe- 
cially  iron,  arsenic  and  quinine ;  at  the  onset  of  the  pelvic  pains 
employ  hot  sitz-baths  and  hot-water  vaginal  douches,  and  give  inter- 
nally such  anti-neuralgics  as  phenacetin. 

Ovarian  Dysmenorrhcea. 

What  is  the  etiology  ? 

This  is  applied  to  a  class  of  cases  associated  with  disease  of  the 
ovaries,  but  the  etiology  is  far  from  settled,  and  the  class  not  distinct. 

What  are  the  symptoms  ? 

Between  the  periods  there  is  pain  and  tenderness  over  the  region 
of  the  ovary,  increased  by  exercise,  defecation  and  coitus ;  these 
symptoms  are  increased  at  the  menstrual  periods. 

Membranous  I)ysmenorrh(ea. 
Describe. 

' '  Membranous  dysmenorrhoea  is  characterized  by  the  expulsion  at 
the  menstrual  periods  of  organized  membranes  either  as  a  whole  or 
in  pieces."  (Reeve.) 

What  is  the  etiology  and  pathology  ? 

These  are  both  matters  of  dispute,  but  we  usually  find  in  these 
cases  chronic  endometritis  and  poor  general  health.  The  inner 
surface  of  the  membrane  is  smooth  and  shows  the  openings  of  the 
utricular  glands ;  its  external  surface  is  rough  and  shaggy  (see  Fig. 
12).  . 

According  to  Hart  and  Barbour,  "  It  is  of  the  greatest  importance 
to  remember  that  it  is  not  a  product  of  conception,  and  should  not 
De  mistaken  for  an  early  abortion. "  It  is  composed  of  the  super- 
ficial layer  of  the  endometrium,  with  increased  connective  tissue ; 
blood  accumulates  under  it  and  dissects  it  off. 

What  are  the  symptoms  ? 

Severe  colicky  pain,  usually  recurring  at  each  period  ;  the  flow  is 


MENSTRUATION— DYSMENORRH(EA. 


10^ 


often  intermittent ;  thus  the  symptoms  resemble  those  of  obstructive 
dysmenorrhoea.     The  course  is  usually  protracted. 
How  would  you  differentiate  membranous  dysmenorrhoea 
from  an  early  abortion  ? 
By  the  absence  of  chorionic  villi  and  by  the  repeated  occurrence 

Fig.  13. 


Sketch  of  a  Dysmenorrhoeal  Membrane  as  seen  under  Water  (Sir  J.  Y.  Simpson). 


What  is  the  treatment  ? 

a.  Between  the  periods — 

Dilate  the  cervix,  curette  the  uterine  canal,  and  apply  to  the 
endometrium  iodized  phenol,  pure  carbolic,  or  tincture  of  iodme. 
h.  During  the  menstrual  period- 
Use  hot  baths,  hot  applications  to  the  pelvis,  and  diaphoretics. 


104  ESSENTIALS  OF  GYNECOLOGY. 

Malformations  of  the  Vagina. 

What  are  the  important  varieties  ? 

a.  Atresia  vaginae ; 
h.  Double  vagina ; 
c.   Absence  of  vagina. 

Atresia  Vagina. 

Give  the  varieties  and  etiology. 

Atresia  of  the  vagina  may  be  either  at  the  hymen,  forming  atresia 
hymenahs,  or  higher  up  in  the  vagina,  forming  atresia  vaginahs. 

Etiology. — Atresia  hymenahs  is  usually  congenital,  from  mal- 
development.  Atresia  vaginalis  is  either  congenital,  or  may  be 
acquired  from  cicatrization  following — 

a.  Sloughing  incident  to  parturition  ; 
h.  Adhesive  vaginitis ; 

c.  Traumatism ; 

d.  Caustics. 

What  are  the  symptoms  of  atresia  vaginae  ? 

They  are  dependent  on  the  accumulation  of  the  menstrual  blood, 
hence  in  congenital  cases  they  are  absent  till  puberty.  The  subjective 
symptoms  of  menstruation  come  on,  but  there  is  no  appearance  of 
blood ;  at  the  next  period  the  subjective  symptoms  are  repeated. 
The  periods  then  usuaUy  come  more  frequently,  and  soon  a  tumor 
forms.  If  the  atresia  is  at  the  hymen,  the  latter  bulges,  and  the 
vagina  is  distended  with  blood,  forming  a  haemato-colpos. 

In  atresia  hymenahs  the  cervix  is  usually  not  dilated ;  in  atresia 
vaginahs  the  dilatation  may  extend  to  the  uterus  and  tubes. 

If  the  atresia  is  acquired,  of  course  there  will  be  no  symptoms  till 
the  menstrual  blood  is  retained. 

What  are  the  results  of  atresia  hymenalis  if  unrelieved  by 
operation  ? 

If  the  hymen  is  thin,  it  may  rupture  ;  if  thick,  the  vagina  may 
rupture  ;  after  rupture,  septicaemia  may  occur. 

What  are  the  results  of  atresia  vaginalis  ? 
The  vagina  may  rupture. 


MALFORMATIONS  OF  THE  VAGINA.  105 

The  uterus  and  tubes  may  become  distended,  forming  hgemato- 
metra  or  haemato-salpinx,  and  may  rupture. 
The  atresia  may  rupture. 
After  rupture,  septicaemia  may  occur. 

Where  else  in  the  genital  tract  than  in  the  vagina  may 
atresia  occur  ?    Give  the  etiology  and  symptoms. 

Atresia  may  occur  at  the  cervix. 

Atresia  of  the  cervix  may  be  congenital,  or  acquired  from  cicatri- 
zation following  parturition,  the  use  of  caustics,  or  from  a  too  close 
trachelorrhaphy.  Symptoms  appear  when  the  menstraal  blood  ac- 
cumulates behind  the  atresia,  and  resemble  those  of  atresia  vaginae. 
The  amenorrhoea  and  enlargement  of  the  uterus  may  make  one 
suspect  pregnancy. 

What  are  the  results  of  atresia  of  the  cervix  if  unrelieved  by 
operation  ? 

If  it  is  present  during  menstrual  life,  the  uterus  and  tubes  become 
distended,  and  are  liable  to  rupture,  with  the  danger  of  peritonitis 
and  death.  If  it  occurs  for  the  first  time  after  the  menopause,  it 
usually  causes  no  trouble. 

What  is  the  character  of  the  retained  fluid? 

During  menstrual  hfe  the  blood  is  of  a  brownish,  chocolate  color ; 
it  is  grumous  and  treacle-like  in  consistency,  kept  from  clotting  by 
the  mucus. 

After  the  menopause,  the  retained  fluid  is  honey-like. 

What  is  the  treatment  of  atresia  of  the  genital  tract  with 
retention  of  the  menstrual  blood  ? 

Aspirate  slowly ;  under  strict  antisepsis  incise  the  obstruction,  and 
maintain  the  opening  by  iodoform  gauze  or  a  rigid  drainage-tube. 

What  are  the  dangers  of  rapid  e-vacuation  of  a  haemato- 
metra  ? 

The  tubes  are  probably  distended,  and  have  formed  adhesions  ; 
the  rapid  collapse  of  the  uterus  would  tend  to  tear  the  tubes  from 
their  adhesions,  with  the  danger  of  rupture  of  the  tubes,  and  perito- 
nitis. 


106 


ESSENTIALS  OF  GYNECOLOGY. 


Malformations  of  the  Uterus. 

What  are  the  principal  varieties  ? 

1.  Kudimentary  uterus ; 

2.  Uterus  bipartitus ; 

3.  Uterus  unicornis ; 

4.  Uterus  bicornis ; 

5.  Uterus  didelphys ; 

6.  Uterus  septus ; 

7.  Infantile  uterus ; 

8.  Congenital  atrophy  of  the  uterus ; 

9.  Complete  absence  of  the  uterus,  very  rare. 

Fig.  14. 


Rudimentary  Uterus  (Veit).     Sa,  sacrum;    U,  solid  rudiment  of  uterus;  h,  rudi- 
mentary liorn;  B,  bladder;  0,  ovary;  T,  Fallopian  tube;  r  round  ligament. 


Describe  the  rudimentary  uterus. 

In  this  case  (see  Fig.  14)  "the  uterus  is  represented  by  a  band  of 
muscular  fibre  and  connective  tissue  on  the  posterior  wall  of  the 
bladder. ' '  (Hart  and  Barbour. ) 

Describe  the  uterus  bipartitus. 

In  the  uterus  bipartitus  (see  Fig.  15)  the  rudimentary  horns  are 
present,  and  are  either  hollow  or  solid  and  cord-like  ;  they  are  con- 
nected to  each  other  and  to  the  vagina  by  the  cervix,  which  is  repre- 
sented by  a  fibrous  band.  The  ovaries,  breasts  and  external  genitals 
may  be  well  developed. 


MALFORMATIONS  OF  THE  UTERUS. 


107 


Describe  the  uterus  unicornis. 

The  body  of  the  uteras  in  this  variety  (see  Fig.  16)  is  long  and 
narrow,  and  is  directed  to  one  side ;  its  fundus  has  attached  to  it  one 
Fallopian  tube  and  ovary  ;  on  the  opposite  side  of  the  body  is  seen 
the  representative  of  the  other  horn,  which  is  either  soUd  or  hollow; 


Fig.  15. 


Uterus  Bipartitus  (Rokitansky).     V,  vagina;  U,  uterus ;  h,  rudimentary  horn;  0, 
ovary;  r,tube;  r,  round  ligament ;  5,  broad  ligament. 


Fig.  16. 


Uterus  Unicornis  (Schroeder).  R,  right  side;  L,  left  side.  The  left  horn  (h)  is  well 
developed  and  communicates  with  the  uterine  cavity.  The  right  horn  is  in  the 
form  of  an  elongated  band:  its  point  of  connection  with  the  Fallopian  tube  is 
indicated  by  the  insertion  of  the  round  ligament,  which  is  hypertrophied.  Other 
letters  as  in  preceding  diagrams. 

connected  with  this,  and  separated  from  it  by  the  attachment  of  the 
round  ligament,  are  the  tube  and  ovary  of  that  side. 

Describe  the  uterus  bicornis. 

In  this  form  (see  Fig.  17)  the  division  into  two  horns  is  distinctly 
visible  externally ;  the  division  is  usually  seen  also  in  the  interior  o£ 
the  uterus  on  section. 


108 


ESSENTIALS  OF  GYNECOLOGY. 


Fig.  17. 


Uterus  Bicornis  UnicoUis  (Schroeder).    r,  round  ligament. 


Fig.  18. 


Uterus  Didelphys.  a,  right  cavity ;  b,  left  cavity;  c,  right  ovary ;  d,  right  round 
ligament;  e,  left  round  ligament;  /,  left  tulie;  g',  left  vaginal  portion,  A,  right 
vaginal  portion;  i,  right  vagina;  }',  left  vagina;  k,  partition  between  the  two 
vaginse.    (From  De  Sinety,  after  Ollivier.) 


'=D< 


.ai.,v  X. 


^-^ 


PvTo.^^^^.  '>US5s^**-.0^- 


MALFORMATIONS  OF  THE  UTERUS. 


109 


What  is  the  uterus  didelphys? 

Here  the  two  halves  of  the  uterus  are  separated  throughout  (see 
Fig.  18).     This  condition  is  very  rare. 

Describe  the  uterus  septus. 

Here  the  division  is  entirely  internal  (see  Fig.  19 ) :  beginning  at 
the  fundus,  it  extends  a  variable  distance  toward  the  os  externum, 
sometimes  reaching  it.  There  is  no  indication  of  the  division  from 
the  outside. 


Fig.  19. 


Fig.  20. 


Uterus  Septus  in  Vertical  Transverse  Section  (Kuss- 
maul).  f7(uterus),  placed  on  septum  which  divides 
cavity  into  two  lateral  portious ;  T,  Fallopian  tubes ; 
F,  vagina  divided  into  lateral  cavities  by  prolonga- 
tion of  septum  downward. 


Infantile  Uterus 
(Schroeder). 


What  is  an  infantile  uterus  ? 

In  this  condition  (see  Fig.  20)  the  cervix  is  2-3  times  longer  than 
the  body,  the  relation  of  cervix  to  body  remaining  as  at  birth.  The 
uterus  as  a  whole  is  smaller  than  normal. 

What  is  meant  by  congenital  atrophy  of  the  uterus  ? 

The  relative  lengths  of  cervix  and  body  (see  Fig.  21)  conform  to 
those  of  a  virgin  uterus,  but  the  whole  uterus  is  atrophied. 


no 


ESSENTIALS   OF   GYNECOLOGY. 


What  is  the  occurrence  of  complete  absence  of  the  uterus ? 

It  is  very  rare  indeed,  and  can  only  be  ascertained  by  a  post- 
mortem examination.  Many  cases  of  supposed  absence  of  the  uterus 
are  proved,  on  autopsy,  to  be  cases  of  mdimentary  uterus. 


Fig.  21. 


Primary  Atrophy  of  the  Uterus  (Virchow). 


Displacements  of  the  Uterus. 

What  do  we  mean  by  a  displacement  of  the  uterus  in  a 
clinical  sense  ? 

' '  Changes  in  the  position  of  the  uterus  only  become  displacements, 
in  the  clinical  sense,  when  they  are  more  or  less  stable.  Limitation 
or  hindrance  of  the  normal  movements  of  the  uterus  is  a  main 
characteristic  of  its  displacements."-  (Schultze.) 

What  are  the  principal  displacements  of  the  uterus  ^ 

a.   Anteversion ; 
h.   Anteflexion ; 

c.  Retroversion ; 

d.  Retroflexion ; 

e.  Prolapse. 


DISPLACEMENTS   OF  THE  UTERUS.  Ill 

What  is  the  difference  between  a  "version"  and  a  "flexion?" 

Iix  a  "version  "  the  canals  of  the  cei-vix  and  body  are  in  the  same 
straight  hne  ;  in  a  "flexion "  they  make  an  angle  with  each  other. 

Anteversion. 

What  is  the  pathology  ? 

Tlie  uterine  axis  is  straightened  (see  Fig.  22),  so  that  the  fondus 
hes  forward,  and  the  cervix  is  directed  backward  toward  the  hoUow 

Fig.  22. 


Anteversion  of  the  Uterus  (Schrceder). 

of  the  sacram  ;  the  uterus  is  usually  enlarged  and  more  rigid, 
especially  about  the  internal  os.  The  pathologically  anteverted 
uterus  is  restricted  in  mobility. 

What  is  the  etiology  ? 

The  chief  causes  are  those  of  a  metritis,  and  pelvic  peritonitis  or 
cellulitis,  thus  :  Subinvolution,  laceration  of  the  cei'vix,  with  sepsis, 
and  other  causes  of  pelvic  inflammation. 

What  are  the  symptoms  ? 

They  are  the  symptoms  of  the  accompanying  metritis,  peritonitis 
or  cellulitis.     One  of  the  most  marked  symptoms  is  frequent  mictu- 


112  ESSENTIALS   OF  GYNECOLOGY. 

ritioD,  due  to  the  pressure  of  the  uterus  on  the  bladder,  the  uterus 
being  fixed  forward  and  not  allowing  the  bladder  to  expand  normally. 
Schroeder  describes  a  discomfort  arising  from  the  motion  of  the 
enlarged,  sensitive,  anteverted  uterus,  occurring  with  the  movements 
of  the  patient.     Menorrhagia  sometimes  occurs. 

What  are  the  physical  signs  ? 

The  cervix  is  far  back,  pointing  toward  the  hollow  of  the  sacrum  ; 
the  body  of  the  uterus  lies  just  above  the  anterior  vaginal  wall,  the 
fundus  just  behind  the  pubis.  The  normal  angle  between  cervix  and 
body  is  obliterated  ;  the  mobility  or  fixity  is  easily  detected. 

What  is  the  treatment  ? 

First  treat  the  accompanying  inflammation  by  hot-water  vaginal 
douches,  iodine  to  the  fornices,  and  boric  acid  and  glycerine  tampons 
behind  the  cervix,  or  both  in  front  and  behind.  Continue  this 
treatment  till  aU  inflammatory  symptoms  have  subsided  and  the 
uterus  is  mobile.  Relief  is  then  sometimes  given  by  a  pessary 
which  raises  the  uterus  as  a  whole. 


Anteflexion. 

What  is  the  pathology  ? 

In  anteflexion  the  body  of  the  uterus  is  bent  forward  on  the 
cervix  (see  Fig.  22) ;  in  order  for  this  to  be  pathological,  there  must 
be  rigidity  at  the  point  of  flexion. 

What  is  the  etiology  ? 

It  may  be  congenital  (puerile,  Schultze)  or  acquired. 

The  most  common  causes  of  the  latter  are  a  metritis  occuning  in 
a  flexible  uterus,  or  an  inflammatory  process  occurring  in  the  utero- 
sacral  ligaments,  drawing  the  upper  portion  of  the  cervix  upward 
and  backward.  This  latter  is  the  most  usual  cause.  Bandl  thinks 
cervical  catarrh  the  first  cause,  extending  to  the  cervical  tissue,  and 
then  to  the  cellular  tissue  in  the  utero-sacral  ligament. 

It  is  sometimes  caused  by  the  adhesions  of  peritonitis  drawing  the 
uppei  portion  of  the  cervix  backward. 


DISPLACE3IENTS   OF  THE   UTERUS. 


113 


What  are  the  symptoms  ? 

a.  DysmeDorrhoea ; 
h.  Sterility ; 

c.  Disturbance  of  bladder  functions — frequent  micturition  ; 

d.  Leucorrhoea ; 

e.  Other  symptoms  are  those  of  the  accompanying  inflammation. 

What  are  the  physical  signs  ? 

The  cervix  lies  rather  high;   the  os  is  directed  downward  and 
forward ;  as  you  pass  the  finger  up  along  the  anterior  wall  of  the 

Fig.  23. 


Anteflexion  of  the  Uterus  (Schroeder). 


cervix,  it  runs  into  a  marked  angle  between  cervix  and  body.  The 
body  can  be  felt  lying  in  front  of  the  cervix,  just  above  the  anterior 
vaginal  wall.  The  cervix  is  often  long  and  the  os  small.  The  uterus 
is  sometimes  both  anteflexed  and  retroverted. 

From  what  must  you  differentiate  an  anteflexion  ? 
From — 1 .  A  fibroid  tumor  in  the  anterior  wall  of  the  uterus  ; 
2,  An  inflammatory  deposit  in  front  of  the  cervix, 
8 


114 


ESSENTIALS   OF  GYNECOLOGY. 


Fig.  24. 


How  would  you  differentiate  an  anteflexed  uterus  from  a 
fibroid  tumor  in  the  anterior  wall  ? 

In  an  anteflexion  you  cannot  feel  the  fundus  elsewhere,  and  a 

sound  passes  when  sharply  curved 
into  the  body  felt  in  front  of  the 
cervix. 

In  a  fibroid  in  the  anterior  wall 
(see  Fig.  24)  the  sound  does  not 
pass  into  the  body  felt  in  front  of 
the  cervix,  but  behind  it,  and  the 
fundus  can  be  felt  above  and  behind 
the  fibroid. 


Sound  passed  to  show  that  a  Fibroid 
of  the  Anterior  Wall  is  not  an 
Anteflexion  (Leblond). 


How  would  you  differentiate 
an  inflammatory  deposit 
from  an  anteflexion  ? 

The  former  is  comparatively  rare, 
but  when  present  is  usually  more 
sensitive  than  an  anteflexion ;  in 
the  case  of  an  inflammatory  deposit 
in  front  of  the  cervix,  a  careful 
bimanual  examination  will  usually 
show  the  fundus  elsewhere. 
During  the  acute,  inflammatory  period  the  sound  is  contra- 
indicated. 

What  is  the  treatment  of  anteflexion? 

First  treat  all  existing  pelvic  inflammation,  by  means  of  hot-water 
douches,  counter-irritation  and  glycerine  tampons.  When  all  inflam- 
matory symptoms  have  subsided,  dilate  the  cervix,  under  antiseptic 
precautions,  with  one  of  the  glove-stretcher  dilators,  and  pack 
the  cavity  with  iodoform  gauze  leaving  it  for  forty-eight  hours. 
Maintain  the  dilatation  by  the  introduction  of  the  graduated 
hard  dilators,  or  sounds,  once  or  twice  a  month  for  two  or  three 
months. 


DISPLACEMENTS   OF  THE  UTERUS. 


115 


Retroversion  and  Retroflexion. 
Define. 

"■Retroversion  may  be  defined  as  the  permanent  dislocation  back- 
ward of  the  fundus  uteri,  when  the  fonn  of  the  ntenis  is  such  that 
axis  of  body  and  axis  of  cervix  are  identical.  Retroflexion  denotes 
the  permanent  backward  dislocation  of  the  fundus  uteri,  with  simul- 
taneous flexion  of  the  uterus  over  the  posterior  surface. ' '  (Harrison. ) 

What  is  the  etiology  and  pathology  ? 

Retroversion  (see  Fig.  25)  may  exist  by  itself,  but  with  retroflexion 
rfhere  is  always  more  or  less  retroversion.     Usually  the  uterus  is  first 

Fig.  25. 


Retroversion  of  the  Uterus  (Schroeder.) 


retroverted,  and  then  intra-abdominal  pressure  continuing,  if  the 
uterus  is  flexible,  the  fundus  is  pushed  backward  and  downward. 
The  combination  of  the  two  is  thus  most  common,  and  is  described 
as  retroversio-flexio  (see  Fig.  26).  Retroversio-flexio  is  most  fre- 
quent in  multiparse  following  parturition,  where  the  ligaments  are 
lax  and  patient  lies  on  the  back,  and  especially  if  the  patient  rises 
before  involution  has  occurred.    It  may  occur,  however,  in  nulliparae 


116 


ESSENTIALS   OF  GYNECOLOGY. 


or  virgins,  from  severe  blows,  falls,  lifting,  straining,  etc. ;  also  from 
inflammatory  adhesions,  drawing  the  uterus  backward. 

The  most  common  agent  in  pushing  a  movable  uterus  behind  the 
perpendicular  is  distention  of  the  bladder ;  intra-abdominal  pressure 
may  then  act  on  the  anterior  surface  of  the  uterus.  Relaxation  of 
the  utero-sacral  ligaments,  and  thickening  and  shortening  of  the 
utero-vesical,  favor  retroversio-flexio. 

Pathologically,  we  usually  find  the  body  of  the  uterus  congested 
and  enlarged,  and  more  or  less  rigidity  at  the  junction  of  cervix  md 
body,  from  development  of  fibrous  tissue. 

Fig.  26. 


Retroversio-flexio- 


What  are  the  symptoms  ? 

1 .  More  or  less  constant  pain  in  the  back ; 

2.  Symptoms  of  pelvic  inflammation ; 

3.  Constipation ; 

4.  Irritability  of  the  bladder ; 

5.  Leucorrhoea ; 

6.  Menorrhagia; 

7.  Dysmenorrhoea,  especially  when  flexion  is  marked ; 


DISPLACEMENTS   OF  THE  UTERUS.  117 

8.  Abortion ; 

9.  Sterility; 

10.  Keflex  neuroses. 

What  are  the  physical  signs  ? 

On  making  the  bimanual  examination,  you  find  the  cervix  nearer 
the  vulva  than  normal,  the  fundus  absent  in  front,  and  the  os  pointing 
more  or  less  forward  ;  on  running  the  vaginal  fingers  along  the  pos- 
terior wall  of  the  cervix,  you  find  a  body  which,  in  a  retroversion, 
continues  the  line  of  this  wall,  in  a  retroflexion  makes  an  angle  with 
it.  This  body  moves  as  a  part  of  the  uterus ;  the  sound  passes 
into  it. 

From  what  must  you  differentiate  retroversio-flexio  ? 

1 .  Fibroid  tumor  on  posterior  wall  of  the  uterus  ; 

2.  Fseces  in  the  rectum ; 

3.  Inflammatory  deposits ; 

4.  Prolapsed  ovary  or  small  ovarian  tumor. 

How  would  you  differentiate  retroversio-flexio  from  a  fibroid 
on  the  posterior  wall  ? 

Make  a  carefal  bimanual  examination.  In  case  of  a  backward 
displacement  of  the  uterus,  we  find  an  absence  of  the  fundus  in  front, 
the  cervix  points  more  or  less  forward,  and  the  sound,  when  intro- 
duced, goes  backward. 

In  case  of  a  fibroid  on  the  posterior  wall,  the  fundus  may  be  felt 
in  front  of  it,  and  the  sound  passes  forward.  The  tumor  may  feel 
more  irregular  and  harder  than  the  uterus. 

How  would  you  differentiate  the  fundus  uteri  from  faeces  in 
the  rectum  ? 

On  bimanual  examination,  the  fundus  can  often  be  felt  forward, 
and  the  sound  passes  forward  ;  the  faeces  have  a  more  doughy  feel 
than  the  uterus ;  if  doubt  exists,  always  empty  the  rectum  before 
making  a  diagnosis. 

How  would  you  differentiate  the  fundus  uteri  from  inflam- 
matory deposits  in  the  pouch  of  Douglas  ? 

During  the  stage  of  acute  inflammation  this  may  be  very  difficult, 
as  the  sound  is  then  contraiudicated.  Finding  the  fandus  in  front 
is  the  chief  element  in  the  diagnosis. 


118  ESSENTIALS   OF  GYNECOLOGY. 

When  acute  inflammation  has  subsided,  introduction  of  the  sound 
will  give  great  assistance. 

How  would  you  differentiate  the  fundus  uteri  from  a  pro- 
lapsed ovary  or  small  ovarian  tumor  ? 

By  making  a  carefal  bimanual  examination,  the  uterus  is  found 
lying  in  front  of  the  prolapsed  ovary  or  tumor.  Assistance  may  be 
given  by  the  use  of  the  sound,  or  drawing  down  the  cervix  with  a 
volsella. 

What  are  the  indications  in  the  treatment  of  retroversio- 
iiexio? 

1.  To  treat  the  i)elvic  peritonitis  or  cellulitis,  if  present,  according 

to  the  regular  methods ; 

2.  To  replace  the  uterus ; 

3.  To  retain  it  in  i3lace. 

What  are  the  methods  of  replacing"  a  retroverted  or  retro- 
flexed  uterus  when  movable  ? 

1.  Place  the  patient  in  Sims'  jDOsition ;  introduce  index  and  middle 
fingers  of  the  right  hand  into  the  posterior  fornix  vaginae ;  have 
patient  breathe  deeply  and  slowly ;  during  an  expiration,  raise  the 
body  of  the  uterus  with  the  backs  of  the  vaginal  fingers  till  it  passes 
the  promontoiy  of  the  sacrum,  then  transfer  one  or  both  fingers  to 
the  fi'ont  of  the  cervix,  and  push  that  back-ward ;  this  throws  the 
fandus  forward. 

2.  Another  method  is  to  replace  the  uterus  while  patient  is  in  the 
dorsal  j^osition,  by  means  of  the  bimanual,  either  vagino-abdominal 
or  recto-abdominal.  In  this  method  the  body  of  the  uterus  is  raised 
by  the  fingers  in  the  vagina  or  rectum  until  it  can  be  grasped  by  the 
external  hand,  when  it  is  then  brought  forward. 

3.  When  the  body  of  the  uterus  is  very  sensitive,  so  that  pressure 
by  the  fingers  is  very  painful,  the  utenis  may  be  replaced  by  means 
of  the  sound,  as  follows :  Introduce  the  sound  with  the  concavity 
backward ;  then  make  the  handle  describe  an  arc  of  a,  circle  from 
behind  forward ;  then  slowly  depress  the  handle  toward  the  perineum ; 
this  throws  the  utenis  forward. 

4.  To  rej^lace  the  gravid  uterus,  the  following  method  is  sometimes 
employed  :  Place  patient  in  the  genu-pectoral  position ;  draw  down 


PESSARIES.  119 

cervix  with  the  volsella,  and  press  fundus  uteri  toward  the  bladder, 
with  the  finger  in  the  rectum. 

When  the  uteras  in  a  retro versio-flexio  is  rigid  at  the  angle  of 
flexion,  we  do  not  expect  to  remove  the  flexion,  but  only  to  correct 
the  version. 

What  are  the  methods  of  replacing  a  retroverted  or  retro- 
flexed  uterus  when  fixed  by  adhesions  ? 

If  signs  of  pelvic  inflammation  are  present,  treat  the  inflammation 
by  hot  douches,  sitz-baths,  wet  pelvic  packs,  attention  to  the  bowels, 
etc.  When  the  inflammation  has  subsided,  the  uterus  may  gradu- 
ally be  replaced  by  cautious  manipulation  and  stretching  of  the 
adhesions,  and  gentle  attempts  at  raising  the  uterus,  a  few  moments 
at  a  sitting,  with  the  fingers  in  the  posterior  fornix  vaginae ;  after 
the  manipulation  insert  a  tampon,  to  be  worn  for  twenty-four  hours. 
The  manipulations  may  be  assisted  by  hot-water  vaginal  douches 
between  the  sittings. 

Schultze's  method  of  forcible  reposition  consists  in  placing  the 
patient  under  anaesthesia,  in  the  lithotomy  position,  inserting  index 
and  middle  fingers  of  left  hand  high  up  into  the  rectum,  and  with 
these  fingers  forcibly,  but  gradually,  elevating  the  fundus  uteri  and 
breaking  up  the  adhesions ;  the  right  hand  is  placed  on  the  abdo- 
men, and  as  the  utems  is  elevated,  it  is  grasped  by  this  external 
hand  and  brought  forward. 

This  method  is  rarely  advisable. 

What  are  the  means  for  retaining  the  uterus  in  place  after 
reposition? 

1.  Pessaries; 

2.  Operative  procedures. 


Pessaries. 

What  are  the  varieties  in  most  common  use  ? 

1.  The  Albert  Smith  ; 

2.  The  Emmet; 

3.  The  Thomas. 
Describe  them. 

They  are  usually  made  of  hard  rubber;  the  Thomas  pessary,  how- 
ever, is  often  made  of  soft  rubber. 


120 


ESSENTIALS   OP  GYNECOLOGY. 


The  Albert  Smith  (see  Fig.  27)  is  a  modification  of  the  Hodge 
pessary  ;  its  anterior  extremity  is  narrow,  the  posterior  broad ;  the 
posterior  extremity  curves  upward  behind  the  cervix,  the  anterior 
downward  away  from  the  urethra. 

The  Emmet  pessary  is  usually  made  of  a  larger  bar  than  the  Albert 
Smith,  and  the  curve  is  much  flattened. 

The  Thomas  (see  Fig.  26)  is  long,  narrow,  and  has  its  posterior 
bar  much  enlarged. 


Fig.  27. 


Fig.  28. 


Albert  Smith  Pessary. 


Thomas  Pessary. 


How  does  a  retroversion  pessary  act  ? 

Not  by  pushing  up  the  body  or  fundus,  but  by  making  the  poste 
rior  vaginal  wall  tense,  thus  drawing  the  cervix  backward,  and  in 
this  way  throwing  the  fundus  forward. 

What  are  the  contraindications  to  the  use  of  a  pessary  ? 

A  pessary  should  not  be  introduced  till  all  pelvic  inflammation  has 
subsided,  and,  as  a  rule,  not  until  the  uterus  can  be  well  brought 
forward;  "but  occasionally,  when  the  uterus  is  elevated  to  about 
the  promontory,  the  pessary  may  be  applied. ' ' 

What  is  the  proper  position  of  a  retroversion  pessary  after 
introduction  ? 

The  broader  extremity  should  lie  behind  the  cervix  and  cuxve 
upward  ;  the  narrow  in  front  and  curve  downward. 


PESSARIES.  121 

How  would  you  introduce  one  of  these  retroversion  pessaries  ? 
They  may  be  introduced  with  patient  either  in  the  dorsal  or  in 
Sims'  position,  preferably  in  the  latter,  and  in  the  following  manner : 
Standing  at  the  side  of  the  table,  near  the  buttocks  of  the  patient, 
separate  the  labia  a  little  with  the  fingers  of  the  left  hand  ;  taking 

Fig.  29. 


Introduction  of  Pessary,  First  Stage  (Hart  and  Barbour). 

the  pessary  by  the  smaller  end  with  the  thumb  and  index  and  middle 
fingers  of  the  right  hand,  introduce  it  between  the  labia,  with  the 
breadth  (jf  the  pessary  in  the  line  of  the  labia  (see  Fig.  29) ;  depress 
the  perineum  with  the  pessary  as  you  introduce  it  about  half  way, 


122 


ESSENTIALS   OF  GYNECOLOGY. 


then  rotate,  so  tliat  the  breadth  of  the  pessary  hes  at  right  angles  to 
the  labia ;  now  grasp  the  external  portion  of  the  pessary  with  the 
left  hand  ;  pass  the  index  finger  or  index  and  middle  fingers  of  the 
right  hand  in  front  of  the  posterior  bar  (see  Fig.  30)  and  carry  the 
pessary  along  the  posterior  vaginal  wall,  being  careful  that  it  does 
not  slip  up  in  front  of  the  cervix. 

Fig.  30. 


Second  Stage :  Pessary  carried  on  by  Finger  (Hart  and  Barbour). 


What  are  the  precautions  to  be  observed  in  the  employment 
of  a  pessary  ? 

A  patient  after  the  introduction  of  a  pessary  should  be  made  to 
walk  a  little  about  the  room,  then  to  sit  on  a  chair  and  cross  one 
knee  over  the  other,  to  ascertain  if  the  pessary  causes  pain ;  if  it 
does,  it  should  not  be  kept  in.  A  patient  should  always  be  told,  on 
leaving,  that  if  the  pessary  causes  her  pain,  she  must  introduce  her 
finger  and  remove  it.     She  should  be  seen  in  a  few  days  after  its 


PESSARIES.  123 

introduction,  to  ascertain  if  the  pessary  is  in  position  and  is  holding 
the  uterus  in  place.  The  pessary  should  he  removed  and  cleaned 
as  often  as  once  a  month ;  in  the  meantime  the  patient  should  be 
instructed  to  use  a  vaginal  douche  for  cleanliness,  two  to  three  times 
a  week. 

What  are  the  operative  procedures  for  holding  a  retroverted 
uterus  in  place  after  reposition  1 

a.  Alexander's  operation;  h.  Hysterorrhaphy,  or  ventral  fixation  ; 
c.  Intra-abdominal  shortening  of  the  round  ligaments ;  d.  Vagino- 
fixation. 

Describe  briefly  Alexander's  operation. 

Alexander's  operation  for  shortening  the  round  ligaments  is  per- 
formed as  follows :  The  skin  about  the  pubes  is  shaved  and  prepared 
antiseptically ;  the  pubic  spine  is  taken  as  the  first  landmark ;  an 
incision  is  then  made,  1^-3  inches  long,  from  that  point  upward  and 
outward,  in  the  direction  of  the  inguinal  canal ;  the  incision  is  deep- 
ened until  the  tendon  of  the  external  oblique  is  seen  ;  the  external 
abdominal  ring  is  now  visible ;  the  intercolumnar  fascia  is  cut  through 
in  the  long  diameter  of  the  ring ;  the  round  ligament  can  usually 
now  be  seen,  with  the  genital  branch  of  the  genito-crural  nerve  along 
its  anterior  surface.  The  ligament  is  then  separated  from  neighboring 
structures  and  gently  drawn  out  a  little  to  show  it  is  free.  Alexander 
then  leaves  this  side  covered  with  a  clean  sponge  and  operates  on 
the  other  side  in  the  same  way.  The  uterus  is  then  thrown  for- 
ward by  the  sound  in  the  hands  of  an  assistant  and  the  ligaments 
drawn  out  till  they  are  felt  to  control  the  uterus;  the  ligaments 
are  then  given  to  an  assistant  to  hold,  and  they  are  each  sutured 
with  catgut  to  the  pillars  of  the  ring ;  the  bruised  ends  are  cut 
off  and  the  wound  closed.  The  patient  is  kept  in  bed  two  to  three 
weeks,  and  wears  a  pessary  for  several  months. 

What  are  the  indications  for  Alexander's  operation  ? 

Where  a  retroverted  uterus  is  movable,  unaccompanied  by  disease 
of  the  appendages,  and  either  cannot,  with  comfort  to  the  patient, 
be  held  in  position  by  a  pessary,  or  the  patient  is  unwilhng  to  wear 
a  pessary,  Alexander's  operation  is  indicated. 


124  ESSENTIALS   OF   GYNECOLOGY. 

What  are  the  advantages  of  Alexander's  operation  as  com- 
pared with  hysterorrhaphy  ? 

In  Alexander's  operation  the  uterus  itself  is  only  held  by  liga- 
ments which  normally  hold  it.  It  is  therefore  better  fitted  for 
growth  in  pregnancy  than  where  the  fundus  is  firmly  attached. 

Another  advantage  is  that  Alexander's  operation  is  performed 
without  opening  the  peritoneum. 

What  are  the  objections  raised  to  Alexander's  operation? 

It  is  not  applicable  unless  the  uterus  is  freely  movable. 
The  ligaments  are  sometimes  difficult  to  find. 
Hernia  occasionally,  though  rarely,  occurs. 

Describe  briefly  the  operation  of  hysterorrhaphy  for  retro- 
versio-flexio. 

The  abdomen  is  opened  in  the  median  line  as  for  an  ovariotomy ; 
the  adhesions  binding  the  uterus  backward  are  broken  up,  the  fundus 
brought  forward  and  the  uterus  stitched  to  the  anterior  abdominal 
wall.  The  sutures  are  usually  two  in  number,  of  either  silk  or  cat- 
gut, preferabl}^  the  former,  and  are  inserted  one  just  posterior  to  the 
middle  of  the  fundus  and  the  other  posterior  to  that,  so  that  when 
the  sutures  are  tied  the  uterus  will  be  slightly  anteverted.  These 
sutures  pass  through  fascia,  muscle  and  parietal  peritoneum  of  one 
side,  then  through  a  portion  of  the  fundus  of  the  uterus,  then 
through  parietal  peritoneum,  muscle  and  fascia  of  the  other  side. 
These  sutures  are  buried  in  the  closure  of  the  abdominal  wound. 

The  usual  antiseptic  dressing  is  applied.  A  pessary  is  often 
inserted  for  a  time. 

What  are  the  indications  for  hysterorrhaphy? 

Hysterorrhaphy  is  indicated  in  a  retroverted  fixed  uterus,  especially 
where  pregnancy  is  improbable ;  in  a  retroverted  uterus  after  the 
removal  of  both  appendages ;  as  one  stage  in  the  operation  for  pro- 
lapsus uteri. 

What  are  the  disadvantages  of  hysterorrhaphy  ? 

Experience  shows  that  in  pregnancy  following  hysterorrhaphy  the 
portion  of  the  uterine  wall  behind  the  point  of  suture  is  that  which 
undergoes  the  chief  distention  and  thinning.  Although  obstetric 
accidents  due  to  the  operation  are  rare,  disturbances  of  parturition, 
and  even  rupture  of  the  thinned  posterior  uterine  wall,  may  occur. 


PROLAPSUS   UTERI.  125 

Describe   briefly  intra-abdominal  shortening-  of  the  round 
ligaments. 

After  opening  the  abdomen  and  separating  the  adhesions,  the 
uterus  is  brought  forward  into  normal  position  and  held  there  by 
taking  up  the  slack  in  the  round  ligaments.  This  is  done  by  folding 
each  round  ligament  upon  itself  and  suturing  the  folds  in  apposition. 

Describe  vagino-fixation  of  the  uterus. 

A  median  longitudinal  incision  is  made  in  the  anterior  vaginal 
wall  from  a  little  behind  the  meatus  nearly  to  the  junction  of  the 
anterior  vaginal  wall  with  the  cervix.  The  bladder  is  separated 
from  the  anterior  surface  of  the  uterus  and  from  the  vaginal  wall 
on  either  side  of  the  incision.  The  bladder  being  pushed  up  out 
of  the  way,  the  peritoneum  is  opened,  and  the  uterine  body  is 
brought  down  into  the  vaginal  incision  and  sutured  there.  The 
vaginal  wound  is  then  closed. 

What  are  the  disadvantages  of  vagino-fixation  of  the  uterus  ? 
It  not  only  fixes  the  uterus  in  an  unnatural  position,  but  a  number 
of  cases  have  been  reported  in  which  during  parturition  serious 
obstruction  has  occurred.  For  these  reasons  the  operation  has 
largely  fallen  into  disuse  in  this  country. 

Prolapsus  Uteri. 
What  is  meant  by  the  expression  ? 

Hart  and  Barbour  define  prolapsus  uteri  as  a  downward  displace- 
ment of  entire  displaceable  portion  of  pelvic  floor,  uterus  and  ap- 
pendages past  entire  fixed  portion,  with  coincident  descent  of  small 
intestine. 

What  is  meant  by  the  "entire  displaceable  portion  of  pelvic 
.  floor  "  ? 

The  entire  displaceable  portion  comprises  bladder,  urethra  and 
vaginal  walls.  It  has  resting  upon  it  the  uterus,  broad  ligament, 
Fallopian  tubes  and  ovaries. ' ' 

What  is  the  "  entire  fixed  portion  of  pelvic  floor  "  ? 

That  outside  of  the  entire  displaceable  portion,  i.  e. ,  tissue  attached 
to  the  posterior  surface  of  the  symphysis ;  all  outside  the  inner 
aspect  of  the  levatores  ani ;  the  rectum  and  tissue  attached  to  the 
sacram. 


126  ESSENTIALS   OF   GYNECOLOGY. 

What  are  the  deg^rees  of  prolapsus  uteri  ? 

According  to  Thomas  there  are  three  : — 

1.  When  the  organ  has  sunk  in  the  pelvis. 

2.  When  the  cervix  is  at  the  ostium  vaginae. 

3.  When  a  part  or  the  whole  of  the  uterus  lies  between  the  thighs. 

What  is  the  etiology  ? 

The  three  elements  in  the  etiology  of  prolapse  are — 

1.  Relaxation  of  the  ligaments  of  the  uterus,  combined  with  lack 
of  tone  in  the  entire  displaceable  portion  of  the  pelvic  floor  and 
"  slackening  of  loose  tissue  around  it. " 

2.  Lack  of  support  in  the  entire  fixed  portion  of  the  pelvic  floor, 
especially  laceration  of  the  perineum. 

3.  Intra-abdominal  pressure. 

The  chief  predisposing  causes  are  parturition,  laborious  occupa- 
tions, anything  increasing  weight  of  the  uterus,  advanced  age.  Pro- 
lapse is  sometimes  produced  acutely  by.  blows,  falls,  heavy  lifting, 
etc. ,  but  is  usually  the  gradual  result  of  the  three  elements  mentioned 
above. 

What  are  the  symptoms  ? 

Those  of  the  acute  prolapse  are  sudden,  severe  pain,  vomiting, 
retention  of  urine  and  signs  of  peritonitis.  The  symptoms  of  the 
gradual  prolapse  are  a  dragging  sensation  in  lower  abdomen  and 
back,  and  the  discomfort  from  the  protrusion  and  excoriation  of  the 
parts ;  difficulty  in  urination  is  sometimes  present. 

What  are  the  physical  signs  ? 

These  depend  on  the  degree  of  the  prolapse.  If  the  prolapse  is 
partial,  the  anterior  vaginal  wall  bulges  at  the  ostium  vaginae,  the 
cervix  is  lower  than  normal,  and  if  there  is  marked  laceration  of  the 
perineum  the  posterior  vaginal  wall  also  bulges.  The  uterus  becomes 
more  and  more  retro  verted  as  it  sinks  in  the  pelvis.  When  the  pro- 
lapse is  complete,  the  cervix  and  more  or  less  of  the  body  of  the 
uterus  lies  outside  of  the  vulva;  the  anterior  vaginal  wall  and  part  of 
the  lower  bladder  wall  have  prolapsed  with  the  cervix;  the  posterior 
vaginal  wall  with  or  without  part  of  the  anterior  rectal  wall  is  also 
everted.    The  uterus  is  usually  enlarged  and  the  cervix  elongated. 


PROLAPSUS   UTERI.  127 

From  what  must  you  differentiate  prolapsus  uteri  ? 

1.  Hypertrophy  of  the  cervix: — 

{a)  Vaginal  portion  ;  (h)  Supra-vaginal  portion  ;  (c)  Intermediate 
portion. 

2.  Cystocele. 

3.  Rectocele. 

4.  Inversion  and  polypi. 

How  would  you  differentiate  prolapsus  uteri  from  a  cysto- 
cele ? 

In  prolapse  the  uterus  is  sunken  in  the  pelvis  ;  in  cystocele  the 
uterus  lies  in  nearly  its  normal  position,  and  the  protruding  mass  is 
found,  by  the  introduction  of  the  sound  into  the  bladder,  to  consist 
of  the  anterior  vaginal  and  posterior  vesical  wall. 
How  would  you  differentiate  prolapsus  uteri  from  a  recto- 
cele? 

In  prolapse  the  uterus  is  sunken  in  the  pelvis ;  in  rectocele,  pure 
and  simple,  the  uterus  lies  in  nearly  its  normal  position,  and  the 
protruding  mass  is  found,  by  the  introduction  of  the  finger  into  the 
rectum,  to  consist  of  the  posterior  vaginal  and  anterior  rectal  wall. 

Both  cystocele  and  rectocele  are  common  complications  of  prolap- 
sus uteri. 
"What  is  the  treatment  of  prolapsus  uteri  ? 

1.  By  pessaries;  2.  By  operation. 

If  the  prolapse  is  slight  in  amount,  the  perineum  preserved,  and 
the  anterior  vaginal  wall  protrudes  but  a  little,  a  pessary  like  that 
of  Albert  Smith  may  suffice  to  hold  up  the  uterus.  If  this  fails, 
a  cradle  pessary  will  sometimes  answer. 

If  the  prolapse  is  marked,  the  following  combination  of  operations 
usually  gives  the  best  result  : 

1.  Curettage  of  the  uterus ; 

2.  Amputation  of  the  cervix ; 

3.  Anterior  colporrhaphy ; 

4.  Perineorrhaphy ; 

5.  Hysterorrhaphy. 

These  can  all  be  done  at  the  same  sitting.     In  some  cases  1,  2,  or 
3  may  be  omitted,  but  in  a  well-marked  case  all  five  are  indicated. 
Vaginal  hysterectomy  is  very  seldom  indicated  for  prolapsus  uteri. 


128  ESSENTIALS   OF   GYNECOLOGY. 


Laceration  of  Perineum  and  Relaxation  of  Vagi- 
nal Outlet. 

What  is  the  etiology  ? 

The  most  common  cause  of  laceration  of  the  perineum  is  child- 
birth, either  natural  or  instrumental ;  rarely,  however,  it  may  arise 
from  external  violence,  as  falling  astride  of  some  sharp  object.  Re- 
laxation of  the  vaginal  outlet,  aside  from  being  produced  by  these 
visible  lacerations,  is  also  caused  by  submucous  and  subcutaneous 
rupture  or  overstretching  of  the  fibres  of  the  levator  ani  muscle,  or 
perineal  fascia  ;  this,  too,  occurs  most  often  during  parturition. 

What  are  the  varieties  of  perineal  laceration  ? 

Lacerations  of  the  perineum  may  be  complete  or  incomplete : 

Complete  when  the  tear  involves  the  sphincter  ani  muscle. 

Incomplete  when  it  does  not  involve  the  sphincter  muscle. 

Incomplete  lacerations  may  vary  from  a  slight  tear  of  the  four- 
chette  to  one  extending  to  the  sphincter  ani  muscle.  The  lacera- 
tion may  be  chiefly  within  the  vagina,  the  skin  perineum  being 
preserved. 

These  internal  lacerations  are  usually  lateral,  extending  into  the 
vaginal  sulci  on  either  side  of  the  rectum. 

Complete  lacerations  are  less  likely  to  be  accompanied  by  relaxation 
and  rectocele  than  are  the  incomplete. 

What  is  the  importance  of  laceration  of  the  perineum  ? 

It  consists  in  the  fact  that  in  cases  of  marked  laceration,  the  fibres 
of  the  levatores  ani,  the  chief  support  of  the  vaginal  outlet,  are  torn; 
especially  those  fibres  which  are  attached  to  the  rectum  ;  at  the  same 
time  there  is  laceration  of  the  fibres  of  the  perineal  fascia.  These 
conditions  cause  relaxation  of  the  vaginal  outlet,  with  a  tendency  to 
rectocele,  cystocele  and  prolapsus  uteri. 

If  the  laceration  is  through  the  sphincter  ani,  incontinence  of 
faeces  usually  results. 

What  are  the  subjective  symptoms  of  laceration  of  the  peri- 
neum with  relaxation  of  the  vaginal  outlet  ? 

The  patient  usually  feels  incapacitated  for  any  great  exertion, 


LACERATION   OF  PERINEUM.  129 

complains  of  a  dragging  pain  in  the  back  and  the  feeling  of  weight 
in  the  pelvis. 

How  would  you  determine  relaxation  of  the  vaginal  outlet? 

Insert  the  thumbs  or  index  fingers  into  the  vaginal  orifice  ;  sepa- 
rate the  labia  by  carrying  the  thumbs  or  fingers  backward  and  out- 
ward, at  the  same  time  telling  the  patient  to  strain  ;  the  lax  condi- 
tion of  the  outlet  will  then  be  readily  felt,  and  anterior  and  posterior 
vaginal  walls  will  be  seen  to  protrude. 

What  are  the  principal  operative  procedures  for  repair  of 
lacerated  perineum  or  relaxation  of  the  vagiual  outlet? 

The  four  following  operations  are  in  common  use— 

1.  Hegar's  operation. 

2.  Emmet's  operation. 

3.  The  Saenger-Tait  operation. 

4.  Cleveland's  operation. 

Fig.  31. 


Describe  the  Hegar  operation.  (Martin  suture.) 

In  this  as  in  all  perineal  operations,  the  patient's  bowels  should 

be  freely  moved  and  the  vulva  shaved.    Just  previous  to  operation, 

the  vagina  and  vulva  should  be  thoroughly  cleansed  with  soap  and 

water  and  then  irrigated  with  an  antiseptic  solution.    In  the  Hegar 

9 


130  ESSENTIALS   OF   GYNECOLOGY. 

denudation  which  is  triangular  in  shape  (see  Fig.  31.)  three  points 
are  taken,  A.  B.  and  C.  That  which  is  to  be  the  apex  of  the  tri- 
angle, A,  is  in  the  median  line  of  the  posterior  vaginal  wall ;  this 
is  seized  with  a  bullet  forceps  or  tenaculum  and  drawn  upward  and 
forward.  The  points  B  and  C,  at  the  extremities  of  the  base  hne, 
are  points  on  the  labia  majora  which  when  the  operation  is  com- 
pleted will  form  tne  fourchette.  These  points  B  and  C  are  also 
seized  by  bullet  forceps  or  tenacula  and  are  drawn  apart,  thus 
facilitating  the  denudation  of  the  triangular  area  A.  B.  C. 

This  denuded  surface  may  either  be  closed  by  sutures  introduced 
from  side  to  side,  or  as  is  usually  done  by  the  author,  it  may  be 
closed  by  a  continuous  catgut  suture  in  tiers  according  to  Martin. 
This  is  similar  to  the  Martin  method  of  suturing  used  in  an  ante- 
rior colporrhaphy.   (See  further  on.) 

When  the  operation  is  completed  the  point  A  is  high  up  in  the 
vagina,  B  and  C  are  in  apposition. 

Describe  Emmet's  operation  for  restoration  of  the  perineum. 

The  patient  is  prepared  for  operation  as  usual,  with  antiseptic 
douches,  etc.  She  is  anaesthetized  and  placed  in  the  lithotomy 
position  ;  a  point  is  selected  in  the  centre  of  the  crest  of  the  bulging 
posterior  vaginal  wall,  and  a  point  on  each  labium  majus  correspond- 
ing to  the  lowest  vestige  of  the  hymen.  These  three  points  are  to 
be  brought  together  by  the  completed  operation. 

Between  the  central  point  chosen  and  the  two  lateral  are  two  triangu- 
lar areas,  with  apices  running  into  the  vaginal  sulci  on  each  side  of  the 
columna.  These  triangular  areas  are  first  denuded  as  follows  :  One 
tenaculum  is  inserted  into  the  central  point  chosen,  and  another  into 
one  of  the  lateral  points  ;  these  are  given  to  an  assistant,  who  draws 
the  central  point  forward  and  to  the  side  opposite  the  other  tenacu- 
lum. This  draws  the  apex  of  the  triangle  nearly  in  line  with  the  two 
tenacula  ;  a  narrow  strip  is  then  denuded  with  the  scissors  along  this 
line.  When  the  tension  is  relieved,  the  area  marked  off  is  seen  to 
be  triangular,  as  before.  The  denudation  of  this  triangle  is  then 
completed  by  long  snips  of  the  scissors.  The  lateral  point  on  the 
other  side  is  now  seized  with  the  tenaculum,  and  the  central  point 
drawn  toward  the  denuded  side  ;  this  triangle  is  denuded  as  before, 
also,  as  much  of  the  skin  surface  of  the  perineum  as  is  necessary. 


LACERATION   OF  PERINEUM. 


131 


The  parts  are  now  thoroughly  irrigated  and  the  sutures  introduced,  cxs 
follows :  The  two  triangular  areas  are  to  be  in  the  vagina,  and  are 
sutured  with  either  silkworm  gut,  chromicized  catgut  or  silk.  The 
apex  of  one  triangle  is  first  closed,  the  suture  entering  and  emerging 
from  the  vaginal  mucous  membrane  near  the  denuded  surface  ;  the 
succeeding  sutures  of  this  triangle  are  made  to  enter  the  vaginal 
mucous  membrane  on  one  side,  slant  toward  the  operator,  emerge  at 
the  centre  of  the  denuded  surface,  reenter,  slant  away  from  the 
operator  and  emerge  from  the  mucous  membrane  of  the  other  side 
a  ^inle  in  front  of  the  preceding  suture.  This  method  is  repeated  in 
the  other  triangle.  There  then  remains  but  a  small  external  denuded 
area  to  be  closed  ;  this  is  best  done  with  silkworm  gut.  The  upper  or 
crown  suture,  entering  the  skin  on  one  side,  passes  through  the  anterior 
extremity  of  the  columna  of  the  posterior  vaginal  wall,  and  emerges 
from  the  skin  on  the  other  side.  The  bowels  arc  moved  about  the 
third  day  and  the  sutures  removed  on  the  eighth. 

Fig.  32.  Fig.  33. 


What  modification  does  episioperineorrhaphy  make  in  these 
operations  ? 
The  denudation  is  carried  higher  on  the  labia  majora  (see  Fig.  32), 
and  the  lower  portions  of  the  latter  arc  united  as  seen  in  Fig.  33. 


132  ESSENTIALS   OF   GYNECOLOGY. 

Describe  the  operation  of  anterior  colporrhaphy. 

This  consists  in  the  denudation  of  an  elliptical  piece  of  mucous 
membrane  from  the  anterior  wall  of  the  vagina,  and  suturing  to- 
gether the  raw  area  thus  formed.  The  ellipse  should  extend  from 
a  little  behind  the  urethral  prominence  to  a  j^oint  just  in  front  of 
the  cervix.  The  denudation  is  usuall^^  best  performed  with  scissors, 
removing  the  mucous  membrane  in  long  strips.  The  strip  to  be 
removed  is  held  taut  with  toothed  thumb-forceps  drawn  toward  the 
operator,  and  the  ridge  thus  formed  is  removed  by  scissors  cutting 
in  the  opposite  direction  and  held  parallel  to  the  surface  of  the 
ridge.  The  suturing  is  best  done,  according  to  Martin's  method, 
hj  a  continuous  suture  of  catgut,  as  follows:  A  line  of  suture 
is  first  made  longitudinally  along  the  centre  of  the  denuded  ellipse ; 
this  reduces  its  size  slightly  ;  another  tier  of  sutures  is  then  inserted 
back  over  the  first,  uniting  tissue  more  superficial  ;  thus  the  sutures 
are  introduced  tier  upon  tier,  each  narrowing  the  denuded  area  and 
causing  the  edges  of  the  mucous  membrane  to  approach  each  other, 
till  finally  in  the  last  tier  these  edges  are  included. 

This  operation  may  be  combined  with  any  operation  on  the  peri- 
neum and  posterior  vaginal  wall. 

Describe  the  Saenger-Tait  operation. 

The  patient  is  prepared  for  operation  by  having  the  bowels  freely 
moved,  the  vulva  shaved,  and  an  antiseptic  vaginal  douche  given. 
She  is  then  anaesthetized  and  placed  in  the  lithotomy  position,  with 
knees  supported  by  Clover's  crutch  and  hips  resting  on  Kelly's 
perineal  pad.  The  vagina  and  vulva  are  now  scrubbed  with  soap-water 
and  irrigated  with  an  antiseptic  solution,  and  an  assistant  so  stationed 
that  he  can  allow  a  mild  antiseptic  solution  or  sterilized  salt  solution  to 
trickle  on  the  wound  during  the  operation.  A  tampon  is  inserted  into 
the  rectum,  the  string  left  projecting.  The  index  and  middle  fingers 
of  the  left  hand  are  now  inserted  into  the  rectum,  as  seen  in  Fig.  34 ; 
the  labia  are  separated  by  an  assistant,  the  blades  of  the  scissors  (Tait 
uses  angular  scissors  and  inserts  only  one  blade;  scissors  curved 
slightly  on  the  flat,  with  jDoints  rather  sharp,  and  both  blades  in- 
serted, may  be  used  with  advantage)  inserted  into  the  recto-vaginal 
septum  just  in  front  of  the  anus,  and  the  vaginal  and  rectal  mucous 
membranes  separated  for  some  distance  around  the  point  of  inser- 
tion.    A  horizontal  incision  is  now  made  through  the  point  of  inser- 


LACERATION    OF   PERINEUM. 


133 


tlon,  extending  on  either  side  to  a  perpendicular  througli  tlie  lower 
extremity  of  tlie  nymplise  ;  an  incision  is  made  with  the  scissors  up 
along  this  perpendicular  to  the  lower  extremity  of  the  nymphae. 
The  flap  so  marked  out  is  then  dissected  up  to  the  crest  of  the 
bulging  posterior  vaginal  wall.     See  Fig.  35. 

The  parts  are  now  freshly  irrigated,  and  the  sutures  of  silver  wire 
introduced  as  follows  :  Either  a  Peaslee's  needle  or  a  long,  .straight 
needle  with  l  thread  loop  maybe  used  ;  the  sutures,  3-4  in  number, 

Fig.  34. 


are  inserted  just  within  the  denuded  area  on  one  side,  and  brought 
out  just  within  the  denuded  area  on  the  other.  See  Fig.  36.  The 
tampon  is  removed  from  the  rectum,  the  sutures  twisted  up  and 
either  left  long  or  shotted  and  cut  short.     The  skin  is  now  brought 


34 


ESSENTIALS   OF  GYNECOLOGY. 


Fig.  35. 


Pig.  36. 


LACERATION   OF  PERINEUM. 


135 


into  apposition  by  superficial  silkworm-gut  sutures  introduced  be- 
tween the  wires,  giving  the  result  seen  in  Fig.  37.  An  antiseptic 
dressing  and  a  T-bandage  are  applied,  and  the  patient  is  put  to  bed. 
The  bowels  are  moved  about  the  third  day,  and  the  sutures  re- 
moved on  the  eighth. 

Fig. 37. 


Fig.  3? 


What  is  a  good  method  of  procedure  when  the  laceration 
extends  through  the  sphincter  ani? 

Thoroughly  cleanse  the  vagina  and  lower  portion  of  the  rectum. 
Denude  a  V-shaped  area  with  apex  up  the  rectum,  representinij 
the  torn  wall  of  the  latter,  and  with  the  arms  of  the  V  resting  on 
the  ends  of  the  divided  sphincter  ani  muscle.  The  denuded  sur- 
face had  best  be  a  little  larger  at  these  latter  points.  Sutures  of 
silk  worm  gut  or  chromicized  gut  are  now  introduced  as  seen  in 
Fig.  34.  with  ends  in  the  rectum  and  tied.  The  silver  wire  suture 
formerly  introduced  around  the  V,  1  2  3  is  best  omitted.    The  ends 


136 


ESSENTIALS   OF   GYNECOLOGY. 


of  the  silk  worm  gut  sutures  are  left  long  and  protruding  from  the 
anus.  This  repairs  the  rectal  rent,  and  now  the  further  restoration 
of  the  perineum  may  be  accomplished  bj^  any  of  the  ordinary 
methods  of  denudation  and  suturing.  The  Hegar's  denudation 
with  Martin's  suture  answers  admirably  here. 

Fig.  39. 


Describe  the  Cleveland  operation. 

Dr.  Cleveland  describes  his  method  in  the  following  words — 
"The  usual  broad  denudation,  extending  well  into  the  sulci  having 
been  made,  the  first  suture  is  passed  in  at  the  centre  (see  Fig.  39. 
A,  1.)  of  the  denuded  surface  on  the  patient's  left,  a  quarter  of  an 
inch  from  the  edge,  is  carried  well  back,  deep  under  the  tissues,  to 
embrace  the  retracted  muscles,  across  between  the  denuded  surface 
and  the  rectum,  to  the  centre  of  the  denuded  surface,  then  down 


LACERATION   OF   PERINEUM.  l37 

and  out  a  quarter  of  an  inch  from  the  edge,  at  a  point  (2,  Fig.  39.) 
midway  between  the  centre  of  the  denuded  surface  on  the  patient's 
right,  and  the  posterior  commissure  D.  It  is  then  carried  over 
without  cutting,  and  entered  at  a  corresponding  point  (3,  Fig.  39.) 
opposite  the  point  where  it  was  brought  out;  then  carried  up, 
buried,  to  the  centre  of  the  denuded  surface,  across,  and  out  a 
quarter  of  an  inch  beyond  the  centre  of  denuded  edge  (4,  J.,  Fig. 
39.),  directly  opposite  the  point  where  it  was  first  introduced.  The 
second  suture,  or  suture  B  in  the  diagram,  is  introduced  just  below 
the  summit  of  the  denudation  on  left  labium  (1,  ^.  Fig.  39.),  and 
passed,  buried  close  to  the  denuded  edge,  around  the  angle  in  the 
left  sulcus  to  the  highest  point  of  denuded  surface  on  the  columna, 
at  C,  then  across,  still  buried,  the  angle  of  right  sulcus  and  out  at 
2.  B,  which  is  a  point  midway  between  summit  and  centre  of  denu- 
dation on  right  labium :  then  carried  over  without  cutting  and  is 
entered  at  3.  i?,  a  point  corresponding  to  the  one  where  it  was  just 
brought  out,  then  across,  buried,  the  angle  of  left  sulcus  to  the 
point  C,  and  finally  passed  around  the  angle  of  right  sulcus  close 
to  the  denuded  edge  and  out  at  4.  B.   a  point  corresponding  to 

1.  b:' 

Dr.  Cleveland  often  introduces  a  third  suture  E.  as  a  protection 
suture.  They  are  usually  of  silk-worm  gut.  The  sutures  are  now 
drawn  up  and  tied  beginning  with  A. 

Describe  the  Stoltz  anterior  colporrhaphy. 

A  circular  area  is  denuded  on  the  anterior  vaginal  wall,  extend- 
ing from  J  inch  behind  the  meatus  to  within  about  the  same  dis- 
tance from  the  cervix.  This  denuded  area  is  brought  together 
with  one  long  silk  suture  with  a  needle  on  each  end  in  the  follow- 
ing manner :  Beginning  just  in  front  of  the  cervix,  a  little  outside 
of  the  raw  area,  one  needle  is  passed  around  one  half  of  the  cir- 
cumference, going  in  and  out  of  the  mucous  membrane  but  not 
entering  the  raw  area.  The  other  half  of  the  suture  is  now  passed 
around  the  other  half  of  the  circumference  in  a  similar  manner. 
The  two  ends  emerge  a  little  behind  the  meatus ;  they  are  crossed 
and  tied,  the  raw  area  being  inverted  as  the  silk  suture  is  drawn  up 
like  a  pucker  string. 


138  ESSENTIALS   OF   GYNECOLOGY. 

Hypertrophy  of  the  Cervix. 

Give  the  varieties  and  etiology. 

Hypertrophy  of  the  cervix  raay  involve  either  the  infra-vaginal 
or  supra-vaginal  portions.  Some  authorities  mention  hypertrophy 
of  the  intermediate  portion  of  the  cervix. 

Little  is  known  of  the  etiology. 

Hypertrophy  of  the  infra-vaginal  portion  is  usually  congenital. 

Hypertrophy  of  the  supra-vaginal  portion  usually  accompanies 
prolapse  of  the  uterus  or  vaginal  walls. 

What  are  the  physical  signs  and  symptoms  ? 

The  OS  is  nearer  vulva  than  normal ;  it  may  even  project  beyond 
the  vulvar  opening. 

In  hypertrophy  of  the  infra-vaginal  portion,  the  cervix  is  long, 
usually  conical,  with  small  os  ;  the  vaginal  fornices  and  fundus  uteri 
are  in  their  normal  position.  If  the  cervix  protrudes  from  the 
vulva,  it  may  be  ulcerated,  from  friction. 

' '  In  hypertrophy  of  the  supra- vaginal  portion  both  anterior  and 
posterior  fornices  are  obliterated. ' ' 

' '  In  hypertrophy  of  the  intermediate  portion  the  posterior  fornix  re- 
mains, while  the  anterior  fornix  is  obliterated .' '    (Hart  and  Barbour. ) 

What  are  the  symptoms  ? 

The  symptoms  of  hypertrophy  of  the  infra-vaginal  portion  are 
chiefly  mechanical : — 

Leucorrhoea,  from  vaginal  irritation. 
Discomfort  in  exercise. 
Sense  of  weight  in  the  pelvis. 
Sterility. 
The  symptoms  of  hypertrophy  of  the  supra-vaginal  portion  are 
those  of  the  prolapse  of  the  uterus  or  vaginal  walls,  which  it  usually 
accompanies. 

What  is  the  treatment  of  hypertrophy  of  the  infra-vaginal 
portion  of  the  cervix  ? 

Amputation  of  the  cervix. 

The  best  method  is  probably  a  circular  amputation,  proceeding 
in  a  manner  somewhat  similar  to  that  employed  in  amputation  of 
an  extremity,  viz,  cutting  through  and  retracting  superficial  struc- 


HYPERTROPHY   OF  THE   CERVIX. 


139 


tures,  go  through  cervix  higher  up,  thus  making  the  portion  of 
cervix  removed  conical.  The  tissues  retract  so  that  the  stump  left 
also  appears  conical,  but  the  superficial  structures  can  easily  be 
brought  over  it.  The  vaginal  mucous  membrane  opposite  the 
uterine  canal  is  stitched  to  the  mucous  membrane  of  the  cervi- 
cal canal  both  anteriorly  and  posteriorly,  care  being  taken  to  make 
the  sutures  include  a  portion  of  the  substance  of  the  cervix  so  as 
to  fasten  the  flaps  down  to  the  stump  to  prevent  oozing  and  pocket- 
ing. At  the  sides  of  the  cervix  the  flaps  will  usually  come  into  easy 
apposition  and  should  be  sutured  together,  taking  care  as  above, 
that  the  sutures  include  the  deeper  structures  and  prevent  oozing. 
The  lines  of  suture  thus  extend  from  the  os  a  little  way  into  each 
lateral  fornix.  Before  the  cervix  is  completely  removed  a  few  of 
the  sutures  may  be  introduced  and  used  as  tractors. 

Another  very  good  method  is  that  of  Simon  and  Marckwald,  in 
which  the  cervix  is  first  divided  by  a  transverse  incision  into  an  an- 
terior and  posterior  lip  ;  a  wedge-shaped  piece  is  then  removed  from 

Fig.  40. 


Marckwald's  method  of  splitting  the  cervix  into  an  anterior  and  posterior  lip  and 
then  uniting  cervical  to  vaginal  mucous  membrane  {Schroeder). 

each  (see  Fig.  40),  and  the  flaps  of  each  lip  are  brought  together  with 
sutures,  either  of  silk  worm  gut,  catgut,  or  silver  wire. 


140  ESSENTIALS   OF  GYNECOLOGY. 

Stenosis  of  the  Cervix. 

What  is  the  etiology  ? 

It  may  be  either  congenital  or  acquired.  When  congenital,  it  is 
usually  associated  with  a  small  uterus.  Stenosis  of  the  external  os 
is  more  frequent  than  of  the  whole  canal. 

Acquired  stenosis  results  from  cicatrization  following  the  use  of 
too  strong  caustics,  endocervicitis,  or  a  too  complete  closure  of  the 
ceiTical  canal  in  a  trachelorrhaphy. 

What  are  the  symptoms  ? 

Dysmenorrhcea  and  sterility. 

What  is  the  treatment  ? 

Dilate  the  cervix  with  one  of  the  glove-stretcher  dilators  and 
maintain  the  dilatation  by  the  occasional  introduction  of  graduated 
sounds.  Iodoform  gauze  packing  may  be  used  for  the  first  few 
days  following  the  dilatation  of  the  canal. 

Laceration  of  the  Cervix. 

What  is  the  etiology  ? 

The  usual  cause  is  parturition  or  abortion  ;  it  occasionally  occurs 
as  a  result  of  mechanical  dilatation  of  the  cervix.  It  occurs  in  par- 
turition in  about  32  per  cent,  of  women  ;  especially  in  tedious,  pre- 
cipitate or  instrumental  deliveries.  It  is  predisposed  to  by  a  rigid 
OS,  faulty  presentation  or  condition  of  the  foetus,  premature  rupture 
of  the  membranes  and  previous  disease  of  the  cervix. 

What  is  the  pathology  ? 

The  laceration  may  be — 

1.  Complete.    Penetrating  the  whole  thickness  of  the  cervix. 

2.  Partial.     Including  cervical  mucous  membrane,  but  not  ap- 

pearing on  the  vaginal  surface. 
It  may  be — 

(a)  Unilateral  (see  Fig.  41). 
{h)  Bilateral, 
(c)    Stellate  (see  Fig.  42). 
The  unilateral  laceration  is  most  apt  to  occur  in  the  Hne  of  the 
right  oblique  diameter  of  the  pelvis,  i.  e. ,  either  anteriorly  and  to 
the  left  or  posteriorly  and  to  the  right,  especially  the  former.    This 


LACERATION    OF   THE   CERVIX. 


141 


is  supposed  to  arise  from  the  greater  frequency  of  the  first  position 
of  the  vertex. 

Bilateral  lacerations  are  usually  more  dangerous  than  those  of  the 
anterior  or  posterior  lip,  because  opening  up  the  cellular  tissue  of  the 
broad  ligaments. 

Stellate  lacerations  are  more  apt  to  be  superficial. 

If  the  surfaces  of  laceration  are  kept  clean,  more  or  less  union 

Fig.  41. 


Single  Laceration.    The  flaps  are  held  apart  with  a  double  tenaculum  {Emmei). 


Fig.  42. 


Multiple  or  Stellate  Laceratiou  {Emmef). 


142  ESSENTIALS    OF   GYNECOLOGY. 

will  occur.  Usually  there  is  partial  union,  with  eversion  and  pro- 
liferation of  the  cervical  mucous  membrane,  hyperplasia  of  the  con- 
nective tissue  and  proliferation  of  the  glandular  structure. 

What  are  the  complications  and  results  ? 

The  most  frequent  complications  are — 

1.  Cellulitis. 

2.  Peritonitis. 

3.  Endometritis,  especially  cervical  endometritis. 
The  common  results  are — 

1.  Subinvolution. 

2.  Chronic  metritis. 

3.  Displacements  of  the  uterus. 

4.  Sterihty. 

5.  Abortion. 

6.  Epithelioma. 

If  the  laceration  has  extended  through  the  anterior  fornix,  a  vesico- 
vaginal or  vesico -uterine  fistula  may  remain. 

What  are  the  symptoms  ? 

The  patient  usually  complains  of  a  feeling  of  weight  in  the  pelvis ; 
leucorrhoea,  disturbances  of  menstruation,  especially  menorrhagia ; 
sterility ;  neuralgia  and  various  reflex  neuroses.  At  the  time  of  the 
laceration  there  may  be  considerable  hemorrhage. 

What  are  the  physical  signs  ? 

On  making  a  vaginal  examination  the  cervix  usually  feels  enlarged 
and  more  sensitive  than  usual ;  the  fissure  can,  as  a  rule,  be  readily 
detected;  also,  if  present,  the  eversion  of  the  cervical  mucous 
membrane,  which  usually  feels  velvety,  often  granular  or  cystic. 
Sometimes  the  eversion  is  so  extreme  that  one  does  not  notice  the 
fissure,  simply  feeling  the  velvety  or  granular  area  about  the  os. 
The  latter  may  be  so  patulous  as  to  admit  the  finger.  On  making 
the  bimanual  examination  the  uterus  is  often  found  enlarged  as  a 
whole ;  cicatrices  may  be  felt  extending  from  the  laceration  into  one 
of  the  vaginal  fornices.  With  the  aid  of  the  speculum  one  sees  the 
erosion  on  one  side  of  or  surrounding  the  os,  and  by  drawing  the 
edges  of  the  laceration  together  with  tenacula  the  extent  of  the  tear 


LACERATION   OF  THE   CERVIX.  143 

is  visible.     Without  this  latter  procedure,  one  is  greatly  deceived, 
in  some  cases,  as  to  the  degree  of  the  injury. 

What  is  the  treatment  ? 

Opinions  differ  as  to  whether  lacerations  of  the  cervix,  unless 
accompanied  by  hemorrhage,  should  be  immediately  repaired  or  not. 
When  hemorrhage  accompanies  the  laceration,  the  cervix  should  be 
drawn  down  to  the  vulva  and  the  laceration  closed  with  silkworm 
gut  or  catgut  sutures. 

The  treatment  after  the  puerperium  is  as  follows :  The  complica- 
tions, if  present,  are  first  treated,  especially  peritonitis  or  cellulitis,  by 
counter-irritation,  hot- water  vaginal  douches,  glycerine  tampons,  etc. 

The  cervical  endometritis  is  treated  by  pricking  the  cysts,  if  pres- 
ent, and  applying  to  the  cervical  mucous  membrane  carbolic  acid, 
iodized  phenol,  or  alumnol,  10  per  cent,  in  glycerine.  The  corporeal 
endometritis  is  treated  by  the  curette,  if  necessary,  and  applications 
as  in  cervical  endometritis. 

The  growth  of  the  squamous  epithelium  over  the  erosions  is  stimu- 
lated by  astringent  applications,  especially  pyroligneous  acid.  Under 
the  above  procedures  the  uterus  often  returns  to  its  normal  size,  and 
the  symptoms  associated  with  the  laceration  disappear. 

If  the  symptoms  continue  after  the  foregoing  treatment,  and 
neither  peritonitis  nor  cellulitis  is  present,  Emmet's  operation  of 
trachelorrhaphy  is  indicated. 

Describe  briefly  the  operation  of  trachelorrhaphy. 

The  patient,  after  the  usual  preparation  regarding  bowels,  bladder, 
and  antiseptic  vaginal  douche,  is  anaesthetized  and  placed  in  the 
dorsal  position,  with  Kelly's  pad  beneath  the  hips,  and  legs  sup- 
ported with  a  leg-holder.  The  vulva  and  vagina  are  thoroughly 
scrubbed  with  soap  and  water,  and  an  antiseptic  douche  given.  The 
perineum  is  retracted  with  a  speculum ;  the  anterior  lip  of  the 
cervix  is  seized  with  a  bullet-forceps,  and  the  uterus  drawn  down 
and  steadied  by  an  assistant. 

The  edges  of  the  laceration  are  now  pared  with  scissors  or  knife, 
giving  the  denuded  area  seen  in  Fig.  43,  and  leaving  enough  mucous 
membrane  in  the  centre  for  the  cervical  canal.  Care  should  be  taken 
to  excise  the  plug  of  cicatricial  tissue  at  the  angle  of  the  laceration. 
The  parts  are  now  irrigated  with  an  antiseptic  solution,  and  the  sutures 


144 


ESSENTIALS   OF   GYNECOLOGY. 


of  silkworm  gut  or  silver  wire  introduced,  usually  3-4  on  a  side,  begin- 
ning at  the  upper  angle.  Each  is  passed  from  the  surface  of  the 
vaginal  portion,  through  the  thickness  of  one  lip,  emerging  in  the 
edge  of  the  undenuded  mucous  membrane  ;  thence  is  passed  into  the 
edge  of  the  undenuded  mucous  membrane  of  the  other  lip,  through 
the  lip's  substance,  and  emerges  on  the  surface  of  the  vaginal  portion. 
The  other  sutures  of  the  same  side  are  introduced  in  a  similar  man- 


FlG.  43. 


Extent  of  Denuded  Surface  and  Course  of  Sutures  according  to  Emmet  {Emmet). 
The  sutures  are  passed  in  order  1,  2,  3,  4 ;  the  course  of  suture  4  alone  is  indicated 

by  letters  a,  h,  c,  d. 


ner,  care  being  taken  to  bring  the  parts  into  close  apposition  and 
leave  no  pockets.  If  the  laceration  is  bilateral,  the  suturing  of  the 
other  side  is  conducted  in  the  same  manner.  The  parts  are  again 
irrigated,  and  the  sutures  tied  or  twisted  up.  A  sterile  dressing  is 
applied  to  the  vulva  and  the  patient  placed  in  bed.  The  sutures 
are  left  8-10  daj^s  ;  they  may  be  left  longer  if  the  peritoneum  is 
repaired  at  the  time  of  the  trachelorrhaphy. 


ENDOMETRITIS.  145 

Endometritis^ 

Define  and  give  the  varieties. 

Endometritis  is  an  inflammation  of  the  hning  membrane  of  the 
uterus ;  it  may  be  either  acute  or  chronic.  Acute  endometritis 
usually  involves  both  cervix  and  body. 

The  chronic  is  often  confined  to  either  cervix  or  body,  and  called 
in  the  former  case  cervical  endometritis,  endocervicitis,  or  chronic 
cervical  catarrh  ;  in  the  latter  case,  corporeal  endometritis. 

Occasionally,  chronic  endometritis  affects  the  whole  uterus. 


AnuTTiJ^poMTiTBTTTa 


What  is  the  etiologyT 

Before  puberty  it  is  rare.  The  most  common  causes  are  the  fol- 
lowing : — 

1.  Traumatism  and  sepsis,  especially  from  dirty  instmments. 

2.  Gonorrhoea. 

3.  Catching  cold  during  menstruation. 

4.  Excessive  coitus  near  menstruation. 

5.  Severe  types  of  the  exanthemata. 

6.  It  is  one  of  the  lesions  in  puerperal  septicaemia. 

What  is  the  pathology  ? 

Usually  the  endometrium  of  both  body  and  cervix  is  involved, 
but  the  former  more  than  the  latter.  The  mucous  membrane  is 
swollen  and  softened  ;  extravasations  of  blood  into  it  occur  ;  the  epi- 
thelium is  in  places  destroyed  and  desquamated.  The  secretion  is 
first  serous,  later  purulent,  perhaps  bloody. 

What  are  the  complications  ? 

The  most  common  are — 

Vaginitis;  Urethritis;  Salpingitis;  Peritonitis. 
What  are  the  physical  signs  ? 

The  cervix  is  enlarged,  soft  and  slightly  sensitive ;  the  endome- 
trium is  very  sensitive  to  the  sound  or  probe,  and  these  should  be 
avoided.  There  is  often  an  erosion  about  the  os,  which  is  usually 
filled  with  a  ropy  secretion.  The  cervix  sometimes  looks  and  feels 
like  that  of  early  pregnancy. 

What  are  the  symptoms  ? 

The  characteristic  symptom  is  the  discharge,  which  is  first  watery, 
10 


146  ESSENTIALS   OF   GYNECOLOGY. 

then  creamy.  In  mild  cases  there  are  usually  no  constitutional 
symptoms  save  a  feeling  of  weight  in  the  pelvis  and  a  slight  malaise. 
In  more  severe  cases  there  is  a  dull  pain  in  the  back  and  pelvic 
region,  irritability  of  the  bladder,  and  a  slight  rise  of  temperature. 

What  is  the  treatment  ? 

Put  the  patient  to  bed ;  give  light  diet ;  move  the  bowels  freely 
with  a  saline  cathartic ;  administer  large  hot  vaginal  douches  (water 
Oviij,  borax  Sviij),  temperature  110°-115°,  three  or  four  times  a  day 
for  the  first  24-48  hours.  Later  insert  glycerine  tampons  and  con- 
tinue douches  less  frequently.  Depletion  by  scarification  of  the 
cervix  is  often  of  value.  Hot  applications  to  the  abdomen  usually 
suffice  for  the  relief  of  pain. 

ChRONICJIsIB  OMETRITIS. 

— -^ — ""— 

What  are  the  varieties  ? 

{a)  Chronic  cervical  endometritis. 

(h)   Chronic  corporeal  endometritis. 

A.   Chrome  Cervical  Endometritis. 

What  are  the  synonyms  ? 

Chronic  cervical  catarrh  and  endocervicitis. 

What  is  the  etiology  ? 

Chronic  cervical  endometritis  is  predisposed  to  by  any  low  state  of 
the  system,  from  whatever  cause  produced. 
The  most  common  exciting  causes  are — 

(a)  Laceration  of  the  cervix. 

(h)  Extension  upward  of  a  vaginitis. 

(c)  Extension  downward  of  a  corporeal  endometritis. 

(d)  Displacements  of  the  uterus,  especially  flexions. 

(e)  Stenosis  of  the  cervix. 

(/)  Traumatism,  especially  septic. 

(g)  Excessive  coitus. 

Qi)   Catching  cold  during  menstruation. 

What  is  the  pathology  ? 

In  mild  cases  the  mucous  membrane  alone  may  be  involved,  but 
often  more  or  less  of  the  substance  of  the  cervix  is  afi'ected.  In  a 
well-marked  case  the  epithelium,  glands  and  interstitial  tissue  are 
all  involved  in  the  change. 


ENDOMETRITIS.  147 

The  cylindrical  epithelium  of  the  canal  proliferates  and  replaces 
the  squamous  epithelium  on  the  vaginal  portion  of  the  cervix.  This 
is  especially  trae  where  the  cervix  is  lacerated,  and  the  cervical 
mucons  membrane  is  everted. 

The  glands  of  the  cervix  are  hypertrophied  and  proliferated,  and 
in  addition  to  this,  according  to  Huge  and  Veit,  the  surface  of  the 
mucous  membrane  is  thrown  into  numerous  folds^  producing  gland- 
ular recesses  and  processes. 

The  connective  tissue  of  the  cervix  is  also  increased. 

The  reddened  areas  about  the  os,  where  cylindrical  epithelium 
has  replaced  the  squamous,  and  the  glandular  structure  has  increased, 
are  called  erosions,  sometimes  wrongly  spoken  of  as  "  ulcerations. 

What  are  the  varieties  of  erosion  ? 

According  to  the  depth  of  the  recesses  in  the  folds  of  the  mucous 
membrane  covered  with  cylindrical  epithelium.  Huge  and  Veit  dis- 
tinguish three  varieties : — 

1.  The  simple  erosion  ;  2.  The  papillary ;  3.  The  follicular. 

When  the  mouths  of  these  recesses  become  occluded,  it  forms 
the  cystic  erosion.  These  cysts  may  enlarge  and  extend  toward 
the  surface  of  the  cervix  where  it  is  covered  with  squamous 
epithelium. 

What  are  the  physical  signs  of  chronic  cervical  endome- 
tritis? 

In  nulliparee  the  cervix  may  feel  normal,  save  a  little  swollen  and 
sensitive  ;  sometimes  the  neighborhood  of  the  os  has  a  granular  or 
velvety  feel. 

In  multiparas,  especially  where  the  cervix  is  lacerated,  the  gran- 
ular area  about  the  os  is  larger,  and  small  cysts  in  greater  or  less 
numbers  can  usually  be  felt. 

What  are  the  symptoms  ? 

The  characteristic  symptom  is  the  leucorrhoea ;  this  may  irritate 
the  vulva,  causing  pruritus. 

Pain  in  the  back  and  loins,  especially  on  exertion,  is  usually  present, 
but  may  be  slight. 

Other  symptoms  are  disturbances  of  menstruation,  especially  men- 
orrhagia,  sterihty  and  reflex  neuroses. 


148 


ESSENTIALS   OF  GYNECOLOGY. 


What  is  the  treatment  ? 

Attend  to  the  general  health  and  remove,  as  far  as  possible,  the 
causes  of  the  endometritis. 

In  mild  cases,  especially  in  nulliparae,  use  hot-water  vaginal 
douches  containing  an  astringent,  as  sulphate  of  zinc  5j-0j. 

If  more  severe,  remove  the  ropy  mucus  from  the  canal  with  a 
large-mouthed  syringe  and  apply  iodized  phenol. 

When  the  cervix  is  cystic  or  much  congested,  prick  the  cysts  or 
scarify  the  cervix. 

Fig.  45. 


Schroeder's  excision  of  the  cervical  mucous  membrane  in  cervical  catarrh. 
Fig.  44.  Line  of  incision  in  mucous  mem-    Fig.  45.  Mucous  membrane  excised  and 
brane.  flap  be  turned  in  on  ab  (Schroeder) . 

If  the  above  treatment  fails,  dilate  the  cervix,  curette  thoroughly 
arid  drain  the  uterus  with  iodoform  gauze. 

Schroeder's  operation  consists  in  dividing  the  cervix  into  an  ante- 
rior and  posterior  lip,  excising  the  mucous  membrane  by  a  Y-shaped 
incision  (see  Fig.  44),  and  turning  in  and  uniting  the  lips  as  seen  in 
Fig.  45. 

When  the  cervix  is  badly  lacerated  trachelorrhaphy  is  indicated. 

J5.    Chronic  Corporeal  Endometritis. 

What  is  the  etiology  ? 

It  sometimes  follows  the  acute,  more  often  begins  as  chronic. 
The  most  common  causes  are — 

1 .  Parturition,  especially  when  the  secundines  are  not  thoroughly 
removed. 


ENDOMETRITIS.  149 

2.  Displacements. 

3.  Traumatism,  especially  septic. 

4.  Tumors,  especially  fibroids  and  polypi. 

5.  Excessive  coitus. 

6.  Extension  of  inflammation  from  the  cervix. 

7.  Chronic  metritis. 

What  is  the  pathology  ? 

The  mucous  membrane  is  diseased  in  one  or  all  of  its  elements. 

1.  The  glands  may  be  chiefly  aff"ected,  being  hypertrophied,  and 
new  glandular  tissue  may  be  developed  by  iufoldings  of  the  mucous 
membrane.     The  glands  may  become  cystic  or  may  atrophy. 

2.  The  cells  and  intercellular  substance  may  be  increased,  and 
constitute  the  characteristic  change. 

3.  The  blood  vessels  may  be  dilated  and  increased. 

4.  All  the  elements  may  be  involved  :  the  glands,  interstitial  tissue 
and  blood  vessels  may  all  be  increased. 

The  hypertrophied  mucous  membrane  may  assume  polypoid  or 
fungous  shapes,  giving  rise  to  the  names  "uterine  fungosities" 
and  ' '  villous  endometritis. ' '  This  is  a  result  of  the  preceding  forms, 
usually  the  mixed,  where  all  parts  are  involved  ;  it  is  especially  apt 
to  arise  from  the  inflammation  started  by  retained  secundines ;  it 
causes  more  hemorrhage  than  the  other  forms. 

Chronic  cervical  endometritis  and  chronic  corporeal  endometritis 
are  often  associated. 

What  are  the  symptoms  of  chronic  corporeal  endometritis  ? 

(a)  Leucorrhoea. 

(b)  Menstrual  disturbances,  especially  menorrhagia. 

(c)  Dysmenorrhoea. 

(d)  Pain  in  back  and  pelvic  region. 

(e)  Sterility. 
(/)  Abortion. 

ig)  Reflex  neuroses. 

What  are  the  physical  signs  ? 

On  bimanual  examination  the  uterus  is  usually  found  more  or  less 
enlarged  ;  perhaps  a  little  tender. 


i50  ESSENTIALS   OF  GYNECOLOGY. 

The  sound,  on  introduction,  shows  the  cavity  enlarged,  and  usually 
detects  iiTegularities  in  its  mucous  membrane  ;  it  frequently  causes 
shght  bleeding. 

What  are  common  complications  ? 

Metritis. 

Salpingitis. 

Peritonitis. 

Displacements. 

Vaginitis. 

What  is  the  treatment? 

1.  Prophylactic. — Be  careful  that  the  uterus  is  thoroughly  emp- 
tied after  labor  or  abortion.  Avoid  exposure  during  menstruation. 
Observe  strict  cleanliness  and  antisepsis  in  the  use  of  uterine  in- 
struments. 

2.  When  no  Irregularities  of  the  Endometrium  are  Detected. — 
Make  occasional  applications  of  iodized  jjhenol  to  the  endometrium. 
Administer  internally,  three  or  four  times  a  day,  fifteen  drops  each 
of  the  fluid  extracts  of  ergot  and  hydrastis  canadensis. 

3.  When  Irregularities  of  the  Endometrium  are  Detected. — If  no 
acute  inflammation  is  present  in  the  neighborhood,  dilate  the  cervix 
and  curette  the  uterus  under  antiseptic  precautions ;  wash  out  the 
uterus  with  an  antiseptic  solution,  making  use  of  a  double-current 
catheter.  The  curetting,  if  thorough,  is  best  done  under  anaesthesia. 
It  is  well  to  confine  the  patient  to  bed  for  a  week,  and  occasional 
applications  of  iodized  phenol  to  the  endometrium  may  be  necessary. 
Drainage  of  the  uterus  with  iodoform  gauze  after  the  curetting  is 
often  of  value. 

Metritis. 

Describe  and  give  the  varieties. 

Metritis  is  an  inflammation  of  the  parenchyma  of  the  uterus,  as 
distinguished  from  that  of  its  mucous  lining  or  serous  covering. 
The  two  varieties  are  the  acute  and  chronic. 


metritis.  151 

Acute  Metritis. 
What  is  the  etiology? 

Acute  metritis  rarely  if  ever  exists  as  an  independent  condition  ; 
it  is  almost  always  associated  with  an  endometritis  or  peritonitis ; 
especially  the  former. 

The  chief  causes  are — 

1.  Septic  infection  during  or  soon  after  labor,  abortion,  or  opera- 
tion ;  2.  Gonorrhoea. 

Acute  metritis  occasionally  arises  from  exposure  to  cold  during  men- 
struation or  sexual  excess,  but  these  usually"  first  produce  endome- 
tritis, secondarily  metritis. 

What  is  the  pathology  ? 

The  uterus  is  enlarged,  especially  antero-posteriorly,  infiltrated 
with  serum,  soft  and  tender.  The  endometrium  is  also  thickened 
and  congested.  The  peritoneal  investment  is  often  covered  with 
lymph.  '■  Microscopically  the  muscular  bundles  are  infiltrated  with 
pus  corpuscles  "  (Hart  and  Barbour).  Circumscribed  abscesses  oc- 
casionally, though  rarely,  occur  in  the  uterine  walls.  These  often 
prove  fatal,  but  sometimes  are  absorbed,  sometimes  become  encap- 
sulated and  cheesy,  and  sometimes  empty  into  the  uterus,  bladder, 
rectum,  vagina,  intestines,  peritoneum,  or  through  the  abdominal 
walls. 

Acute  metritis  may  resolve  at  the  end  of  a  week  ;  it  may  pass  into 
the  chronic  form  ;  if  a  result  of  puerperal  infection,  it  is  often  fatal. 

What  are  the  symptoms? 

They  usually  resemble  those  of  acute  endometritis,  but  are  more 
severe.  The  disease  is  often  ushered  in  with  a  rigor  ;  temperature 
and  pulse  rise ;  there  is  pain  in  the  hypogastrium  and  in  pelvis. 
The  uterus  is  very  tender  on  pressure  ;  there  is  nausea,  usually  vesi- 
cal and  rectal  tenesmus,  and  menstruation,  as  a  rule,  is  disturbed, 
sometimes  suppressed  ;  more  often  menorrhagia  is  present. 

What  is  the  treatment? 

If  due  to  sepsis,  try  to  remove  the  cause ;  giving,  if  necessary, 
intra-uterine  irrigations  of  bichloride  (1-5000).  Keep  the  patient 
quiet  in  bed;  apply  poultices  or  turpentine  stupes  to  the  hypogas- 
trium ;  if  temperature  is  very  high,  use  the  ice  coil.     Empty  the 


152  ESSENTIALS  OF  GYNECOLOGY. 

bowels  with  saline  cathartics ;  if  pain  is  very  severe,  allow  opium  by- 
suppository.  Later,  employ  long  hot-water  douches  and  glycerine 
tampons. 

Chronic  Metritis. 
What  are  common  synonyms? 

Areolar  hyperplasia  (Thomas).  Chronic  parenchymatous  inflam- 
mation of  the  womb  (Scanzoni).  Diffuse  interstitial  metritis  (Noeg- 
gerath). 

What  is  the  etiology? 

According  to  Hart  and  Barbour,  the  causes  may  be  divided  as 
follows : — 

(a)  Causes  which  operate  through  interference  with  the  normal 
involution  of  the  puerperal  uterus. 

(b)  Causes  which  operate  through  the  production  of  repeated  or 
protracted  congestion  of  the  uterus. 

{A)  Frequent  causes  of  subinvolution  are — 

1.  Retained  secundines. 

2.  Laceration  of  the  cervix. 

3.  Pelvic  inflammation  following  parturition. 

4.  Rising  too  soon  after  parturition. 

5.  Non-lactation. 

6.  Repeated  miscarriages. 

(B)  Causing  repeated  or  protracted  congestion  are  the  following — 

1.  Chronic  endometritis. 

2.  Displacement  of  the  uterus. 

3.  Tumors  near  the  uterus. 

4.  Chronic  pulmonary,  cardiac,  hepatic  or  nephritic  disease. 

5.  Excessive  coitus. 

Chronic  metritis  sometimes  follows  the  acute  but  usually  begins  as 
chronic. 

What  is  the  pathology  ? 

The  pathological  changes  may  be  divided  into  three  stages — 
1.  Hypersemic;  2.  Hyperplastic;  3.  Sclerotic. 

In  the  first  or  hyperaemic  stage  the  uterus  is  enlarged,  soft,  tender, 
and  contains  more  blood  than  normal. 

In  the  second  or  hyperplastic  stage  there  is  an  increase  of  the 
intermuscular  connective  tissue,  with  or  without  a  slight  increase  of 


Metritis.  153 

the  muscular  tissue.     The  vascularity  is  decreased  by  the  growth  of 
connective  tissue  around  and  compressing  the  blood  vessels. 

The  third,  or  sclerotic  stage  is  a  result  of  the  former,  the 
uterus  becoming  more  dense,  less  and  less  vascular  and  finally 
atrophied. 

What  are  the  symptoms  ? 

Most  of  the  symptoms  are  either  due  to  the  increased  size  of  the 
uterus  or  to  the  complicating  endometritis.  The  symptoms  usually 
date  from  parturition  or  abortion.     The  following  are  common — 

A  feeling  of  weight  in  the  pelvis. 

Pains  radiating  to  the  back,  limbs  and  different  parts  of  the  body. 

Irritability  of  bladder  and  rectum. 

Leucorrhoea. 

Menstrual  disturbances,  especially  menorrhagia,  due  to  the  endo- 
metritis. 

Abortion  in  the  early  stages. 

Sterility,  later. 

Keflex  neuroses. 

What  are  the  physical  signs  ? 

The  uterus  in  the  early  stages  is  uniformly  enlarged,  soft  and 
tender ;  later  harder,  and  in  the  late  stages  irregularities  of  shape 
may  be  detected.  The  canal  is  enlarged  in  all  its  dimensions  and  the 
sound  passes  easily.  The  os  is  usually  patulous  ;  the  cervix  may  be 
large  and  nodular. 

From  what  must  you  differentiate  chronic  metritis  ? 

From  early  pregnancy,  small  fibroid  tumors  and  malignant  disease. 

How  would  you  differentiate  chronic  metritis  from  early 
pregnancy. 

In  early  pregnancy  the  enlargement  of  the  uterus  is  more  in  the 
antero-posterior  diameter  ;  in  metritis  the  enlargement  is  more  uni- 
form. 

In  pregnancy  the  lower  uterine  segment  is  more  compressible ;  in 
metritis  less  compressible. 

The  uterus  is  tender  in  metritis,  usually  not  in  pregnancy. 

In  pregnancy,  also,  the  cessation  of  menstruation  and  the  soften- 
ing of  the  cervix  usually  aid  us  in  the  diagnosis. 


]54  ESSENTIALS   OF  GYNECOLOGY. 

How  would  you  differentiate  chronic  metritis  from  fibroid 
tumors  ? 

In  small  fibroid  tumors  of  tlie  uterus,  the  irregular  shape  is  con- 
trasted with  the  more  uniform  enlargement  in  metritis.  The  uterine 
cavity  is  usually  more  spacious  in  chronic  metritis  than  when  fibroids 
are  present. 

The  sound  will  often  aid  in  the  diagnosis.  In  some  cases  it  is 
justifiable  to  dilate  the  cervix  and  introduce  the  finger  to  determine 
the  presence  or  absence  of  a  submucous  fibroid  tumor. 

How  would  you  differentiate  chronic  metritis  from  malignant 
disease  of  the  uterus  ? 

Malignant  disease  of  the  uterus  is  more  apt  to  occur  late  in  life ; 
metritis  earlier. 

Cachexia  and  menorrhagia  are  more  marked  in  the  former  than  in 
the  latter. 

What  are  common  complications  of  chronic  metritis  ? 

(a)  Chronic  endometritis. 

(b)  Salpingitis. 

(c)  Peritonitis, 
(c?)   Ovaritis, 
(e)    Vaginitis. 

(/)  Displacements. 

What  is  the  treatment  of  chronic  metritis  ? 

1.  Prophylactic. — Care  during  and  after  confinement. 

2.  Curative. — 

First  treat  the  complications,  if  present,  especially  endometritis 
and  displacements,  in  the  usual  manner.  Attend  to  the  general 
health,  bowels,  exercise,  etc.  Let  the  patient  rest  a  part  of  each 
day,  especially  at  menstruation ;  limit  coitus.  Weir  Mitchell's 
treatment  of  rest,  over-feeding  and  massage  is  sometimes  of  value. 

Local  treatment. — Prolonged  hot- water  vaginal  douches;  glycer- 
ine or  boroglyceride  tampons ;  tincture  of  iodine  to  cervix  and  fornices 
of  the  vagina  ;  scarification  of  the  cervix  with  Buttle' s  spear. 

Emmet's  operation  of  trachelorrhaphy,  or  amputation  of  the 
cervix  by  the  Simon  and  Marckwald  method  is  sometimes  indicated. 


FIBROID  TUMORS   OF  THE  UTERUS.  155 


Atrophy  of  the  Uterus. 

What  is  the  etiology  ? 

It  is  the  natural  condition  after  the  menopause,  and  is  produced 
artificially  by  the  removal  of  ovaries  and  tubes.  It  is  sometunes 
associated  with  phthisis  and  other  exhausting  diseases.  It  occurs  as 
a  superinvolution  after  childbirth,  especially  as  a  result  of  metritis, 
peritonitis,  ovaritis  or  salpingitis.  This  superinvolution  is  the  variety 
of  most  importance. 

What  are  the  symptoms  ? 

Amenorrhoea. 
Sterihty. 
Reflex  neuroses. 

What  are  the  physical  signs  ? 

The  uterus  is  small,  both  in  body  and  cervix,  and  the  canal  is 
shortened. 

What  is  the  treatment  ? 

Attend  to  the  general  health. 

Before  the  menopause,  galvanism  of  the  uterus  and  ovaries  may 

be  tried. 

The  treatment  is  generally  unsatisfactory. 

Fibroid  Tumors  of  the  Uterus. 

What  are  common  synonyms  1 

Fibro-myomata  and  myomata.  Strictly  speaking,  fibro-myomata 
is  the  more  correct  designation,  as  the  tumors  are  composed  of  both 
fibrous  and  muscular  tissue. 

What  is  the  etiology  ? 

Little  is  known  of  the  cause  of  fibroids.  They  are  much  more 
common  in  the  African  than  in  the  white  race  ;  are  most  frequently 
found  between  the  ages  30-45,  and  are  said  to  be  more  common  in 
married  than  in  unmarried  women.  They  rarely,  if  ever,  begin  be- 
fore puberty,  and  never  after  the  menopause. 

What  is  their  structure  ? 

Fibroids,  or  fibro-myomata  of  the  uterus,  are  tumors  composed  of 


156  ESSENTIALS   OF   GYNECOLOGY. 

both  fibrous  and  muscular  tissue,  either  of  which  may  predominate 
over  the  other.     The  fibrous  tissue  is  usually  in  excess. 

Those  comjDosed  chiefly  of  fibrous  tissue  are  usually  more  or  less 
encapsulated  and  of  slow  growth. 

Those  composed  chiefly  of  muscular  tissue  are  rare,  not  encapsu- 
lated, and  are  of  rapid  growth. 

Fig.  46. 


IM.  Interstitial  fibroids. 
SM.  Submucous.    (Schroeder.) 

What  are  their  situations  ? 

They  are  much  more  frequent  in  the  body  of  the  uterus  than  in  the 
cervix.  They  are  most  often  found  on  the  posterior  wall,  next  in 
frequency  on  the  anterior  wall,  rarely  on  the  lateral  walls.  The  soft, 
rapidly-growing  fibroids  are  more  frequent  in  the  fundus. 

The  tumors  always  begin  in  the  substance  of  the  uterine  walls ; 


FIBROID  TUMORS   OF  THE   UTERUS. 


157 


they  may  continue  their  growth  there  ;  may  extend  into  the  uterine 
cavity,  Hfting  up  the  mucous  membrane,  or  outward,  hfting  up  the 

peritoneum.      Hence  the  three 

Fig. 47.  .   ^. 

varieties  : — 

1.  Interstitial. 

2.  Submucous. 

3.  Subperitoneal. 


Describe  the  three  varieties. 

Tlie  interstitial  or  intramural 
fibroids  (see  Fig.  46),  are  usually 
multiple  and  are  situated  in  the 
substance  ofthe  uterine  wall.  The 
submucous  fibroid  (see  Fig.  47), 
may  be  either  sessile  or  attached 
by  a  long  pedicle.  In  the  latter 
case  it  is  called  a  fibrous  polypus. 

The  subperitoneal  or  subserous 
fibroids  (see  Figs.  48  and  49), 
are  often  multiple  ;  may  be  ses- 
sile or  pedunculated  ;  may  grow 
upward  into  the  abdominal  cavity 
and  draw  uterus  up,  or  grow  downward  into  the  pelvis,  and  perhaps 

Fig.  48. 


Submucous  fibroid.    (Schroeder.) 


Subperitoneal  Fibroid. 

become  incarcerated.  They  may  form  adhesions  with  other  organs, 
get  their  nutrition  through  the  adhesions  and  become  detached  from 
the  uterus. 


158 


ESSENTIALS   OF  GYNECOLOGY. 


Fig.  49. 


What  changes  may  occur  in  fibroids  ? 

1.  They  may  undergo  softening  due  to  cBdema  or  myxomatous 
degeneration,  rarely  fatty  degeneration.  By  this  softening  fibro- 
cysts  may  be  formed. 

2.  They  may  undergo  hardening,  due  to  {a)  atrophy,  especially 
after  the  menopause,  or  removal  of  ovaries  and  tube.s.  The  mus- 
cular tissue  degenerates,  and  the  fibrous  tissue  contracts,  (h)  Calci- 
f  cation,  with  the  deposit  of  lime  salts,  beginning  usually  in  the  centre, 
sometimes  at  the  periphery. 

3.  They  may  suppurate.  This 
occurs  most  often  in  submucous 
fibroids,  especially  after  instru- 
mental traumatism  ;  rarely  in  the 
subperitoneal  variety  after  tor- 
sion of  the  pedicle. 

4.  Submucous  fibroids  may 
become  more  and  more  peduncu- 
lated, forming  polypi.  They  are 
sometimes  extruded  from  the 
uterus.  Sometimes  the  capsule 
ruptures,  and  spontaneous  enu- 
cleation occurs. 

What  changes  occur  in  the 
uterus  ? 

The  muscular  wall  hypertro- 
phies, especially  in  the  submu- 
cous or  interstitial  varieties.  The 
mucous  membrane  also  hyper- 
trophies, both  in  glands  and  connective  tissue, 
mucous  membrane  sometimes  ulcerates. 

Changes  in  the  position  of  the  uterus  are  often  produced  : — 

1.  It  may  be  drawn  up  into  the  abdomen. 

2.  It  may  be  prolapsed. 

3.  It  may  be  inverted,  especially  from  submucous  fibroids  attached 
to  the  fundus. 

Describe  briefly  fibroids  of  the  cervix. 

They,  too,  may  be  either  interstitial,  submucous  or  subperitoneal ; 
they  are  usually  hard  and  single. 


Subperitoneal  Fibroid. 


Over  the  tumor  the 


FIBROID   TUMORS   OF  THE  UTERUS.  159 

The  subperitoneal  often  grow  out  between  the  folds  of  the  broad 
ligament. 

The  submucous  and  interstitial  are  apt  to  become  pedunculated 
and  form  polypi.  The  interstitial  fibroid  of  the  cervix  is  sometimes 
mistaken  for  inversion  of  the  uterus. 

What  are  the  symptoms  of  fibroid  tumors  of  the  uterus  ? 

1.  Hemorrhage. — First,  menorrhagia,  later  metrorrhagia;  this 
occurs  especially  in  the  submucous  variety. 

2.  Pain. — (a)  Dysmenorrhoea,  chiefly  in  the  submucous  variety. 

(6)  Pain  due  to  pressure  on  the  pelvic  nerves  or  to 
peritonitis  around  the  tumor. 

3.  Symptoms  due  to  pressure  : — 

On  bladder,  causing  : — 

Irritability. 

Retention. 

Cystitis. 
On  urethra,  causing: — Difficulty  in  micturition. 

Perhaps  retention. 
On  ureter,  causing  : — Hydronephrosis. 
On  rectum,  causing  : — Constipation. 

Sometimes  tenesmus. 

Rarely  complete  obstruction. 
On  pelvic  nerves,  causing  : — 

Neuralgia. 

Numbness. 
On  veins,  causing  : —  Varicosities. 

4.  Sterility. 

5.  Abortion. 

What  are  the  physical  signs  ? 

Except  in  the  case  of  some  subperitoneal  fibroids,  the  uterus  is 
enlarged. 

If  within  reach,  a  tumor  is  felt,  harder  than  the  muscular  sub- 
stance of  the  uterus,  and  movable  with  the  uterus  unless  it  is  attached 
with  a  very  long  pedicle. 

If  it  is  a  small  fibroid  in  the  cervix  it  may  bulge  into  the  vagina  and 
resemble  inversion  of  the  uterus. 

If  it  is  a  submucous  fibroid,  high  up  in  the  uterus,  the  sound  may 


160  ESSENTIALS  OP  GYN^iCOLOGT. 

detect  it,  but  often  it  is  necessary  to  dilate  the  cervix  and  introduce 
the  finger. 

If  it  is  subperitoneal  and  on  the  anterior  wall,  a  hard  mass  is  felt  in 
the  anterior  fornix  moving  with  the  utems  ;  the  fandus  may  be  felt 
above  and  behind  it,  and  the  sound  on  introduction  does  not  pass  iato  it. 

If  on  the  posterior  wall,  a  hard  mass  is  felt  in  the  posterior  fornix  ; 
the  bimanual  shows  fandus  in  front  of  it,  and  the  sound  passes  in 
J&ont  of  it. 

If  it  is  a  large  fibroid  extending  into  the  aMomen,  it  is  flat  on  per- 
cussion unless  intestine  overhes  it ;  auscultation  may  detect  the  ute- 
rine s<3uffle,  especially  at  the  sides,  and  the  mass  seems  to  belong  to 
the  uterus. 

From  what  must  you  differentiate  a  fibroid  tumor  of  the  uterus  ? 
Chronic  metritis. 
Flexions  of  the  uterus. 
Pregnancy. 
Ovarian  cyst. 
Ectopic  gestation. 
Pelvic  hematocele. 
Inflammatory  deposits. 
Inversion  of  the  uterus. 

How  would  you  differentiate  a  small  fibroid  tumor  from 
chronic  metritis  ? 

Small  Fibroid  vs.  Chronic  Metritis. 

Enlaigement  not  uniform,  usually      Enlargement  uniform. 

hard  irregularities. 
Less  sensitive.  More  sensitive. 

Os  usually  unaffected.  Os  usually  everted. 

Both  conditions  may  co-exist. 
The  differential  diagnoses  between  fibroids  and  flexions  of  the 
uterus  have  ah«ady  been  given  (see  i>age  114,  ¥ig.  24). 

How  would  you  differentiate  a  fibroid  tumor  from  preg'nancy  ? 

fibroid  Tumor  vs.  Pregnancy. 

Meustraation  eoutinues  ;  usually      Amenorrho&a  is  the  rule. 

increased. 
Cervix  not  softened.  Cervix  softened. 


FIBROID   TUMORS   OF  THE   UTERUS. 


161 


Later. 

Absence  of  positive  signs  of  preg-      Positive  signs  present, 
nancy. 

How  would  you  differentiate  a  fibroid  tumor  from  an  ovariat 
cyst? 

Fibroid  Tumor  vs.  Ovarian  Cyst. 

Hard  and  firm.  Soft  and  elastic. 

More  intimately  connected  with      Less  intimately  connected  w'.tb 

uterus.  uterus. 

More  central.  More  lateral. 

Menorrhagia  common.  Menstruation  normal  or  irregu- 

lar ;  menorrhagia  rare. 

How  would  you  differentiate  a  fibroid  tumor  from  an  ectopic 
gestation  ? 

Fibroid  Tumor  vs. 

No  menstrual  period  skipped. 


Grows  less  rapidly. 

More  central. 

More  intimately  connected  with 

uterus. 
No  decidual  membrane  cast  oflf. 
Absence  of  attacks  of  very  severe 

sharp  pain,  with  symptoms  of 

collapse. 


Ectopic  Gestation. 

Menstrual     period    or     periodsi 

usually  skipped. 
Grrows  more  rapidly. 
More  lateral.  ' 
Less  intimately  connected  with 

uterus. 
Decidual  membrane  cast  off. 
Such  attacks  occur. 


How  would  you  differentiate  a  fibroid  tumor  from  a  pelvic 
haematocele  ? 


Fibroid  Tumor 
Gradual  development. 
Absence  of  acute  symptoms. 

Insensitive  to  pressure. 
Hard  and  firm. 
Moves  with  utei-us. 
u 


vs.  Pelvic  Hmmatocele. 

Rapid  development. 
Symptoms  of  sudden  sharp  pain, 

shock  and  hemorrhage. 
Sensitive  to  pressure. 
First  soft,  later  harder. 
Does  not  move  with  uterus. 


162  ESSENTIALS   OF   GYNECOLOGY. 

How  would  you  differentiate  a  fibroid  tumor  from  a  pelvic 
infliimmatory  deposit  ? 

Fibroid  Tumor  vs.  Injiammatory  Deposit. 

Slow  growth  ;  no  history  of  acute      History  of  rapid   development, 

inflammation.  and  acute  inflammation. 

Moves  with  uterus,  and  seems  a      Usually    does    not    move    with 
part  of  it.  uterus,  and  seems  less  a  part 

of  it. 
Insensitive  to  i^ressure.  Sensitive  to  pressure. 

What  is  the  treatment  ? 

A  fibroid  if  small  may  give  rise  to  no  sjanptoms  and  need  no 
treatment. 

Treatment,  if  needed,  maj^  be  (1)  paUiative  or  (2)  curative. 

Palliative  Treatment. — [a)  Drugs. — The  administration  of  ergot 
alone  or  in  combination  with  hydrastis  may  control  the  symptoms  until 
the  menopause  is  reached,  when  the  tumor  usually  diminishes  in 
size ;  the  menopause,  however,  is  often  considerably  delayed. 

ih)  Curettage. — If  the  symptoms  are  chiefly  menorrhagia  or 
metrorrhagia,  a  thorough  curettage  of  the  uterus,  followed  at  inter- 
vals by  astringent  applications  to  the  endometrium,  will  often  give 
marked  relief. 

(c)  Diminution  of  blood-supply. — Ligation  of  the  uterine  arteries 
from  the  vagina  has  proven  of  value  in  some  cases,  but  is  uncertain. 

Tait's  operation  of  removal  of  the  ovaries  and  tubes  has  in  many 
cases  been  not  only  palliative  but  curative  ;  of  late,  however,  it  has 
been  abandoned  in  favor  of  hysterectomy. 

Curative  Treatment. — This  consists  of  either  myomectomy  or  hys- 
terectomy. 

Describe  the  operation  of  myomectomy. 

iNIyomectomy  consists  in  exposing  the  tumor  in  the  uterus,  either 
from  the  abdomen  or  vagina,  incising  the  capsule,  enucleating  the 
tumor,  and  closing  its  bed  with  catgut  sutures. 

This  operation  is  indicated  where  the  tumor  can  be  easily  removed 
without  serious  mutilation  of  the  uterus. 

What  are  the  varieties  of  hysterectomy  ? 

Hysterectomy,  removal  of  the  uterus,  may  be  performed  : 


FIBROID   TUMORS   OF  THE   UTERUS.  163 

(a)  Through  the  YSigma— vaginal  hysterectomy,  indicated  when 
the  uterus  and  tumor  are  small. 

ih)  Through  the  abdomen— «5fZo?7i?«a?  hysterectomy,  indicated 
when  the  uterus  and  tumor  are  large. 

Describe  the  operation  of  vaginal  hysterectomy  for  fibro- 
myoma  uteri. 

This  differs  from  the  operation  described  under  carcinoma  uteri 
only  in  the  fact  that  in  cases  where  fibro-myomata  are  large  enough 
to  cause  symptoms  the  uterus  with  its  tumors  is  often  too  large  to 
come  through  the  vagina  without  removing  it  piecemeal,  i.  e.  by 
morcellation.  After  thorough  disinfection  of  vulva  and  vagina,  the 
uterus  is  curetted  and  irrigated  with  a  sterile  solution ;  the  cervix 
is  drawn  down  and  separated  from  its  vaginal  attachments ;  the 
peritoneum  is  opened  anteriorly  and  posteriorly  and  the  uterine 
arteries  are  tied  on  both  sides.  If  the  uterus  is  too  large  to  be 
removed  as  a  whole,  wedge-  or  disc-shaped  pieces  are  removed  from 
its  centre  or  the  uterus  is  divided  in  the  median  line  and  each  half 
removed  separately,  care  being  taken  to  keep  up  traction  on  the 
uterus  by  volsellse  placed  above  the  part  to  be  removed.  The  broad 
ligaments  are  either  hgated  in  section,  or  if  more  convenient  during 
the  operation,  they  maybe  clamped,  and  after  the  uterus  is  removed 
these  clamps  may  or  may  not  be  replaced  by  ligatures  according  to 
the  judgment  of  the  operator.  After  the  removal  of  the  uterus, 
the  pedicles  are  inverted  into  the  vagina  and  sterile  or  iodoform 
gauze  placed  against  them. 

Describe  the  operation  of  abdominal  hysterectomy  for  fibro- 
myoma  uteri. 

For  many  years  the  safest  and  best  method  was  considered  to  be 
that  which  left  the  cervical  stump,  after  amputation  of  the  uterus, 
attached  to  the  lower  angle  of  the  abdominal  wound,  as  in  a  Porro 
operation  on  a  pregnant  utems.  Of  late,  under  improved  tech- 
nique and  with  the  assistance  of  the  Trendelenburg  posture,  which 
raises  the  pelvis  and  gives  ready  access  to  its  contents,  this  method 
has  given  way  to  two  methods  which  differ  from  each  other  in  one 
point— viz.  the  treatment  of  the  cervix. 

a.  In  one  the  cervix  is  removed— total  extirpation.  With  this 
are  associated  the  names  Eastman,  Martin,  Chrobak,  Polk. 


164  ESSENTIALS   OF  GYNECOLOGY. 

h.  In  the  other  the  cervix  is  left  in  the  abdominal  cavity — 
supravaginal  hysterectomy.     This  is  called  Baer's  method. 

In  both  of  these  methods,  after  opening  the  abdomen,  the  broad 
ligaments  are  tied  in  section  and  cut  close  to  the  uterus. 

In  the  total  extirpation  this  ligation  and  cutting  is  continued 
down  to  the  vagina :  this  is  freed  from  the  cervix  and  the  whole 
uterus  removed. 

In  the  supravaginal  hysterectomy  (Baer)  the  ligation  and  cut- 
ting of  the  broad  ligaments  is  continued  until  the  cervix  is  reached 
and  the  uterine  arteries  are  tied  and  cut ;  the  uterus  is  then  ampu- 
tated at  the  cervix,  and  the  latter  is  left,  the  vagina  not  being 
opened. 

In  each  of  these  methods  flaps  of  peritoneum  are  taken  from 
the  anterior  and  posterior  surfaces  of  the  uterus  before  its  removal, 
and  before  closing  the  abdomen  these  flaps  are  brought  together 
over  the  pedicles  in  the  bottom  of  the  pelvis. 


Inversion  of  the  Uterus. 

What  is  the  pathology? 

In  inversion,  the  uterus  is  turned  more  or  less  completely  inside  out 
(see  Fig.  50). 
It  may  be  either — 

1.  Partial — where  the  depressed  uterine  wall  does  not  extend 
beyond  the  os  externum  ;  or 

2.  Complete — where  the  inverted  body,  covered  with  mucous 
membrane,  lies  outside  of  the  os  externum,  either  in  the  vagina  or 
between  the  labia. 

The  mechanism  of  production  of  the  inversion  is  as  follows  : — 
A  portion  of  the  uterine  wall  loses  its  tone,  is  depressed  into  the 
uterine  cavity,  usually  by  traction  from  below  or  abdominal  pressure 
from  above ;  the  depressed  portion  is  then  grasped  by  the  unde- 
pressed portion  and  forced  toward  or  through  the  cervix. 


INVERSION  OF  THE  UTERUS. 


165 


The  peritoneum  follows  the  depression  of  the  uterine  wall,  and 
lines  the  cup  thus  formed.  The  appendages  may  or  may  not  lie 
within  the  cup. 

The  inversion  occurring  during  the  puerperium  usually  begins  at 
the  placental  site  ;  when  produced  by  intra-uterine  tumors,  it  usually 
begins  at  the  attachment  of  the  tumor.  The  uterine  mucous  mem- 
brane is  usually  congested  ;  it  may  ulcerate  ;  sometimes  it  becomes 
gangrenous.  Occasionally  it  becomes  covered  with  squamous  epi- 
thelium, and  resembles  skin. 

Fig.  50. 


Inversion  of  Uterus  (half-size,  Barnes  from  Orosse^s  essay).  The  fundus  lies  in  the 
vagina ;  the  cervix  is  not  inverted ;  the  lips  are  flattened  out  to  a  swelling  seen 
below  the  angle  of  inversion.  The  ovaries  (seen  from  behind)  are  not  in  the 
peritoneal  cup. 


What  is  the  etiology? 

Inversion  is  predisposed  to  by — 

{a.)  Parturition. 

Qj. )  Distention  of  the  uterus  from  any  cause. 

(c.)  Intra-uterine  tumors. 

{d. )  Degeneration  of  uterine  walls. 
According  to  the  time  and  cause  of  production,  two  varieties  are 
recognized  : — 

1.  Puerperal. — Produced  during  the  puerperium,  either  by  ab- 


166  ESSENTIALS  OF  GYNECOLOGY. 

dominal  pressure  or  mismanagement  in  the  delivery  of  the  placenta, 
especially  the  latter,  traction  on  the  cord  being  one  of  the  most  fre- 
quent causes. 

2.  Non-puerperal. — Secondary  to  intra-uterine  tumors ;  especially 
pedunculated  fibroids  growing  from  the  fundus. 

The  puerperal  variety  is  much  more  common  than  the  non-puer- 
peral. The  former  is  usually  rapid  in  development ;  the  latter 
gradual. 

When  the  inversion  is  developed  and  reduced  during  the  puer- 
perium,  it  is  called  acute  ;  otherwise,  chronic  inversion. 

What  are  the  symptoms  ? 

At  the  time  of  the  occurrence  of  acute  inversion,  there  is  pain, 
hemorrhage,  shock,  a  feeling  as  of  something  giving  way,  and  of  full- 
ness in  the  vagina. 

This  belongs  especially  to  obstetrics. 

The  symptoms  of  the  chronic  inversion  are  hemorrhage,  dragging 
pain  in  the  pelvis,  discomfort  from  the  foreign  body  in  the  vagina, 
leucorrhoea,  anaemia  and  general  malaise.  Rarely  inversion  exists 
with  very  few  symptoms. 

What  are  the  physical  signs  ? 

These  depend  on  whether  the  inversion  is  partial  or  complete,  acute 
or  chronic.  In  the  partial  variety  the  cupping  may  be  felt  by  the 
hand  on  the  abdomen,  and  the  inverted  portion  detected  by  the  use 
of  the  sound  in  the  uterus.  In  the  acute,  complete  inversion,  one 
feels  a  soft,  bulging  tumor  in  the  vagina  or  between  the  labia ;  it 
bleeds  easily,  is  sensitive  and  smaller  above  where  it  is  encircled  by 
the  cervix  ;  it  may  or  may  not  have  the  placenta  attached  to  it.  The 
sound  passes  around  the  tumor,  but  only  a  short  distance  into  the 
cervix.  The  hand  on  the  abdomen  detects  the  absence  of  the  fundus 
and  the  presence  of  the  cervical  ring.  The  physical  signs  of  the 
chronic  inversion  are  similar,  save  that  the  mass  in  the  vagina  is 
smaller,  harder,  and  in  the  non-puerperal  variety  perhaps  has 
attached  to  it  the  tumor  which  was  its  cause. 

From  what  must  you  differentiate  inversion  of  the  uterus? 
From  polypi  and  prolapsus  uteri. 


INVERSION   OF  THE  UTERUS. 


167 


How  would  you  differentiate  inversion  of  the  uterus  from  a 
polypus  ? 

The  diagnosis  of  a  complete  inversion  (see  Fig.  51)  from  a  polypus 
lying  in  the  vagina  (see  Fig.  52)  would  be  made  as  follows : — 


Inversion 

Fundus  not  felt  in  the  abdomen  ; 

cervical  ring  felt. 
Sound  passes  all  around  tumor, 

but  only  a  short  distance  into 

the  cervix. 


vs.  Polypus. 

Fundus  felt  in  the  abdomen. 

Sound  passes  into  the  uterus,  at 
the  side  of  the  tumor,  more 
than  2j  inches. 


Fig.  52. 


Fig.  51. 


Inversion  of  Uterus  (after 
Thomas).  A  cup-shaped 
depression  is  in  the  place 
of  the  uterus.  Sound  ar- 
rested at  angle  of  flexion. 


Uterine  Polypus  (after 
Thomas).  The  uterus 
in  its  normal  position. 
Sound  passes  into 
uterine  cavity. 


The  differential  diagnosis  between  a  partial  inversion  and  an  intra- 
uterine polypus  (see  Figs.  53  and  54)  is  often  quite  difficult.  Careful 
examination  by  the  ordinary  bimanual  and  by  the  abdomino-rectul 
method  may  detect  the  cup-shaped  depression  of  the  partial  inver- 


168 


ESSENTIALS   OF   GYNECOLOGY. 


sion.     Enlargement  of  the  uterus  rather  favors  the  diagnosis  of 
polypus. 
Both  of  these  conditions  may  rarely  coexist. 

How  would  you  differentiate  inversion  of  the  uterus  from 
complete  prolapse  ? 

This  rarely  causes  difficulty.  It  is  made  by  finding  in  the  latter 
the  external  os,  the  obliteration  of  the  fornices,  and  by  passing  the 
sound  into  the  uterine  canal. 

What  are  the  results  of  an  untreated  inversion  ? 

Yery  rarely  it  reduces  itself  Rarely  the  patient  suffers  little 
inconvenience  from  it. 

Usually  the  patient  dies  from  hemorrhage  or  sepsis. 

Fig.  54. 
Fig.  53. 


Partial  Inversion  of  Uterus 
(after  Thomas). 


Polypus  still  Intra-uf  erine 
(after  Thomas). 


What  is  the  treatment  ? 

The  object  sought  is  the  reposition  of  the  fundus  uteri. 

Emmet's  method  (see  Fig.  55)  consists  in  inserting  the  right  hand 
into  the  vagina,  grasping  the  fundus  in  the  palm,  inserting  the 
fingers  into  the  cervix  and  pushing  upward  ;  at  the  same  time  sepa- 
rating the  fingers  as  much  as  possible.  The  left  hand  meanwhile 
exercises  through  the  abdomen  counter-pressure  on  the  cervical  ring. 

Noeggerath  begins  the  reposition  by  dimpling  in  one  horn  of  the 
uterus,  and  then  uses  this  as  a  wedge  to  dilate  the  cervix. 


POLYPI. 


109 


Instead  of  the  hand  alone,  cup-shaped  repositors  are  often  made 
use  of. 

In  all  these  methods  the  patient  is  usually  best  prepared  for  the 
manipulation  by  the  administration  of  prolonged  hot-water  douches, 
and  the  introduction  of  a  vaginal  elastic  bag,  to  be  distended  with 
air  or  water,  and  worn  twelve  to  twenty-four  hours. 

The  manij^ulations  are  best  jDcrformed  under  anaesthesia. 

When  the  above  methods  fail,  hysterectomy  i:»robably  offers  the 

best  result. 

Fig.  55. 


Reposition  of  the  Inverted  Uterus  with  the  Hand  alone  (after  Emmet). 


Polypi. 

"What  is  meant  by  the  term  ** uterine  polypus,"  and  what 
are  the  varieties? 

A  polypus  is  a  pedunculated  tumor  attached  to  the  uterine  mucous 
membrane.     The  following  varieties  are  recognized  : — 

1.  Fibrous  polypi. 

2.  Mucous  polypi. 

3.  Pedunculated  Nabothian  follicles. 

4.  Placental  polypi. 

5.  Papillomata  of  the  cervix. 


]70 


ESSENTIALS   OF   GYNECOLOGY. 


Describe  briefly  the  fibrous  polypi. 

Fibrous  polypi  are  submucous  fibroids  whicb  have  becorae  pedun- 
culated ;  at  first  lying  witliin  the  uterus ;  later,  dilating  the  cervix 
and  becoming  vaginal  (see  Fig,  56),  sometimes  even  projecting 
beyond  tbe  vulva. 

They  spring  from  the  muscular  wall  of  the  uterus,  more  often 

Fig.  56. 


Intra-uterine  Submucous  Fibroid  which  is  becoming  Vaginal  {Sir  J.  Y.  Simpson). 

from  the  body  than  cervix ;  they  are  composed  chiefly  of  fibrous 
tissue  with  few  blood  vessels.  Their  presence  sets  up  uterine  con- 
tractions, which  gradually  expel  them.  Their  shape  is  usually 
pyriform  or  ovoid. 

Describe  the  mucous  polypi. 

These  spring  from  the  uterine  mucous  membrane,  chiefly  that  of 
the  cervix.    There  are  usually  more  than  one  (see  Fig.  57)  ;  they  are 


POLYPI. 


171 


small,  soft,  vascular,  and  on  section  present  the  structure  of  mucous 
membrane. 

What  are  the  pedunculated  Nabothian  follicles  ? 

They  are  the  glands  of  the  cervical  mucous  membrane  which  have 
become  obstructed,  formed  retention  cysts  and  assumed  the  polypoid 
shape. 

What  are  placental  polypi  ? 

They  are  portions  of  undetached  placenta  which  have  received  nutri- 

FiG.  57. 


Group  of  Mucous  Polypi  growing  in  the  Cervix  Uteri  {Sir  J.  Y.  Simpson). 

mcnt  from  their  attachment  to  the  uterus,  have  become  coated  with 
fibrin  and  so  increased  in  size.  By  the  uterine  contractions  they  are 
made  more  pedunculated,  and  may  be  extruded  from  the  cervix. 

Describe  the  papillomatous  variety  of  polypus. 

Papilloma  of  the  ceivix  is  almost  always  either  a  malignant  new 
growth  or  tends  soon  to  become  so.  It  is  often  called  a  ' '  cauli- 
flower excrescence"  (Clarke),  (see  Fig.  58),  is  usually  soft,  friable, 
and  bleeds  easily. 


172 


ESSENTIALS   OF   GYNECOLOGY. 


What  are  the  symptoms  of  polypi  ? 

1.  Hemorrhage. — First  menorrhagia,  then  metrorrhagia,  the 
source  of  the  blood  being  the  mucous  membrane,  which  covers,  or 
in  the  mucous  variety  forms,  the  substance  of  the  polypus. 

2.  Leucorrhoea. — Due  to  the  accompanying  endometritis. 

3.  Pain.— Due  to  the  efforts  of  the  uterus  to  expel  the  tumor. 

4.  Sterility. — Due  to  the  mechanical  obstruction  and  to  the  endo- 

metritis. 
^^*=^-58.  5.  Anaemia  and  general  malaise. — 

Resulting  from    the    foregoing  condi- 
tions. 

What  are  the  physical  sig^ns  ? 

When  the  polypus  has  passed  the  os 
externum,  the  finger  in  the  vagina  de- 
tects a  pyriform  or  ovoid  body,  hard  or 
soft  according  to  the  variety;  it  is 
movable  and  seems  to  come  from  the 
OS.  The  use  of  the  speculum  deter- 
mines its  appearance. 

If  it  is  a  fibrous  polypus,  the  bi- 
manual examination  usually  shows  the 
uterus  enlarged,  and  the  sound  proves 
the  cavity  elongated. 

When  the  polypus  is  intra-uterine, 
the  sound  in  some  cases  will  detect  its 
presence ;  in  other  cases  dilatation  of 
the  cervix  and  introduction  of  the  fin- 
ger is  necessary. 

The   fibrous  polypus,   according    to 
Hart  and  Barbour,  is  larger  than  a  wal- 
nut and  of  firm  consistency. 
The  mucous  polypus  is  about  the  size  of  an  almond  and  of  a  pulpy 
consistency. 

For  differential  diagnosis  between  inversion  of  the  uterus  and 
polypi  see  inversion. 

What  is  the  treatment? 

When  the  polypus  is  of  considerable  size  and  lies  within  or 


Cauliflower  Excrescence  growing 
from  the  Cervix  Uteri  {Sir  J. 
Y.  Simpson). 


CARCINOMA  UTERI.  l78 

external  to  the  os,  the  best  treatment  is  removal  by  the  wire 
ecrasem,  putting  the  wire  loop  as  near  the  uterine  attachment  of 
the  pedicle  as  possible. 

Small  polypoid  projections  may  be  scraped  away  with  the  curette  ; 
mucous  polypi  may  usually  be  twisted  oif  with  the  forceps. 

When  the  polypus  lies  within  the  uterus,  dilate  the  cervix  and 
apply  the  ecraseur. 

If  the  pedicle  is  small,  blunt,  dull  scissors  may  be  substituted  for 
the  ecraseur.  If  the  pedicle  is  large  or  dilatation  of  the  ceiTix  i. 
necessary,  anaesthesia  is  to  be  employed. 

All  antiseptic  precautions  are  to  be  used. 


Carcinoma  Uteri. 

What  is  the  patholog^y  ? 

Carcinoma,  with  its  usual  microscopical  characteristics,  may  involve 
either  the  body  of  the  uterus  or  the  cei-vix  ;  it  is  very  much  more 
frequent  in  the  latter,  and  the  usual  form  is  epithelioma.  It  may 
begin  on  the  vaginal  portion  of  the  cervix,  in  the  substance  of  the 
cervix,  or  in  the  mucous  membrane  of  the  canal. 

When  situated  on  the  vaginal  portion  it  often  begins  as  an  indu- 
ration of  the  superficial  layers,  which  then  ulcerate  with  irregular 
and  indurated  edges.  It  may  take  the  form  of  cauliflower  excres- 
cences. 

When  beginning  as  nodules  in  the  substance  of  the  cei-vix,  these 
nodules  enlarge,  come  to  the  surface  of  the  mucous  membrane  and 
ulceration  follows. 

When  beginning  in  the  mucous  membrane  of  the  canal,  it  may 
excavate  the  whole  canal  and  extend  to  the  parametrium. 

Carcinoma  of  the  body  of  the  uterus  usually  begins  in  the  endo- 
metrium. Whether  it  ever  begins  in  the  substance  of  the  uterine 
wall  is  a  disputed  point.  It  may  be  circumscribed  or  diffuse.  It 
often  assumes  a  polypoid  shape. 

What  is  the  etiology  ? 

The  etiology  of  cancer  of  the  uterus  is  still  unsettled.  The  factors 
which  favor  its  development  are  age,  heredity,  paiturition,  laceration 
of  the  cervix,  with  erosion  and  depreciation  of  the  vital  powers. 


174  ESSENTIALS   OF  GYNtECOLOGY. 

1.  Age. — It  occurs  most  frequently  between  the  ages  of  40-50. 

2.  Heredity. — Although  regarded  as  of  less  importance  than  for- 
merly, its  influence  seems  to  be  exemplified  in  some  cases. 

3.  Parturition. — Frequent  child-bearing  apparently  creates  a 
marked  predisposition, 

4.  Laceration  of  the  Cervix. — Cancer  of  the  cervix  seems  often  to 
arise  from  a  laceration,  with  erosion  and  cervical  endometritis. 

5.  Depreciation  of  the  Vital  Powers. — Poor  surroundings,  poor 
food  and  air  and  hardships  of  any  kind  seem  to  predispose  to  cancer. 

What  are  the  symptoms  ? 

1.  Hemorrhage. — This  is  usually  the  first  symptom.  If  hemor- 
rhage occurs  after  the  menopause,  always  suspect  cancer. 

2.  Offensive  Discharge. — Does  not  occur  until  ulceration  begins. 

3.  Pain. — When  the  cervix  is  alone  involved,  pain  is  usually  ab- 
sent. When  the  disease  has  extended  to  the  cellular  tissue  or  peri- 
toneum, or  involves  the  body   of  the  uterus,  pain  is  common. 

4.  Cachexia. — This  is  always  present  to  a  greater  or  less  extent 
in  the  later  stages. 

What  are  the  physical  signs? 

If  the  disease  aifects  the  vaginal  portion  of  the  cervix,  the  exam- 
ining finger  detects  ai'ough,  ulcerated  and  indurated  area,  or  perhaps 
a  fungoid  mass.  On  withdrawal,  the  finger  is  usually  stained  with 
blood  and  emits  a  foul  odor.  The  speculum  gives  us  the  appearance 
of  the  growth. 

When  the  uterine  canal  is  involved,  the  sound  usually  detects  the 
abnormal  condition,  which  may  be  diagnosed  by  microscopical  exam- 
ination of  fragments  removed  by  curetting.  In  cancer  of  the  body, 
the  uterus  is  usually  enlarged. 

What  is  the  treatment  of  carcinoma  of  the  uterus  ? 

1.  Radical. — 

When  the  disease  is  limited  to  the  uterus,  either  cervix  or  body, 
vaginal  hysterectomy  is  indicated.  Aside  from  the  appearance  of 
the  diseased  area  viewed  through  a  speculum,  the  mobility  of  the 
uterus  largely  determines  whether  or  not  the  disease  has  extended 
beyond  it.  If  the  uterus  is  fixed  in  the  pelvis,  hysterectomy  is 
usually  contraindicated. 


CARCINOMA  UTERI.  175 

2.  Palliative. — When  a  radical  operation  is  contraindicated,  the 
following  methods  of  treatment  are  of  value  : — 

If  hemorrhage  is  a  marked  symptom,  and  sloughing  masses  are 
present  at  the  seat  of  ulceration,  thoroughly  curette  the  surface  and 
apply  carbolic  acid,  iodized  phenol,  or  a  solution  of  chloride  of  zinc. 
Frequent  insertions  of  iodoform  gauze  soaked  in  a  4  per  cent,  solu- 
tion of  chloral  will  be  found  to  act  as  an  antiseptic  and  anaesthetic  to 
the  ulcerated  surface. 

For  the  foul  discharges,  vaginal  douches  of  a  weak  solution  of  creo- 
lin  are  valuable. 
■  The  pain  and  distress  in  the  later  stages  demand  opium. 

Attention  to  the  general  health  is  of  course  indicated. 

Describe  briefly  the  operation  of  vaginal  hysterectomy. 

DiiFerent  operators  differ  somewhat  in  the  details  of  the  operation. 
The  main  features  of  the  operation  are  as  follows:  The  vulva  is 
shaved,  and  the  vagina  and  vulva  thoroughly  disinfected.  The 
uterus  is  drawn  down  and  held  by  an  assistant;  a  semicircular 
incision  is  made  around  the  cervix  in  the  anterior  fornix,  and  the 
cervix  is  separated  from  the  bladder  up  to  the  utero-vesical 
pouch  of  the  peritoneum.  The  ceiTix  is  drawn  forward  and  the 
posterior  fornix  opened  by  a  semicircular  incision  about  the  cervix, 
which  is  then  freed  up  to  the  pouch  of  Douglas.  The  pouch  of 
Douglas  may  now  be  opened,  and  a  clean  sponge  with  a  long  piece  of 
silk  attached,  introduced  to  keep  back  the  intestines.  The  uterus  is 
freed  from  the  lower  portion  of  the  broad  ligaments  by  ligaturing 
in  section,  and  then  cutting  with  scissors  close  to  the  uterus.  The 
latter  may  now  be  retroverted  through  the  opening  in  the  pouch  of 
Douglas,  and  freed  from  the  upper  portion  of  the  broad  ligaments 
by  ligaturing,  and  cutting  close  to  the  uterus.  It  is  well  to  draw 
the  ovaries  into  the  ligature,  so  that  they  will  be  removed  with  the 
uterus.  The  anterior  reflection  of  peritoneum  may  now  be  divided, 
or,  as  practiced  by  many  operators,  this  may  be  done  before  retro- 
verting  the  uterus.  All  hemorrhage  is  checked  and  the  parts  are 
cleaned ;  the  peritoneum  is  sometimes  stitched  to  the  vaginal  wall. 
The  parts  are  dusted  with  iodoform,  and  an  iodoform  gauze  vaginal 
dressing  applied. 

►Some  use  clamps  throughout  the  operation  instead  of  ligatures. 


176  ESSENTIALS   OF   GYNECOLOGY. 

Sarcoma  of  the  Uterus. 

What  is  the  pathology  ? 

Sarcoma,  a  new  growth  developing  from  the  connective  tissue  and 
presenting  the  microscopical  characteristics  of  sarcoma  elsewhere, 
occurs  in  the  uteras,  either  in  the  form  of  a  diffuse  infiltration  or  as 
a  circumscribed  tumor.  It  usually  affects  the  body  of  the  uterus, 
being  rare  in  the  cei'vix.  The  masses  are  usually  grayish  in  color, 
soft  and  brain-like ;  occasionally  the  circumscribed  masses  are  firm 
and  resemble  fibroids,  but  have  no  capsule.  They  usually  do  not 
ulcerate  as  rapidly  or  deeply  as  carcinoma,  and  metastases  are  less 
common. 

What  is  the  etiology  ? 

Little  is  known  concerning  it.  It  is  most  frequent  between  the 
ages  forty  to  fifty,  but,  unhke  carcinoma,  often  occurs  in  nulliparous 
women. 

What  are  the  symptoms  ? 

1.  Hemorrhage. 

2.  Watery  discharge. 

3.  Pain. 

4.  Cachexia. 

Thus  the  symptoms  are  similar  to  those  of  carcinoma.  Some 
authors  claim,  however,  that  the  discharge  is  less  offensive  than  in 
carcinoma,  because  there  is  less  tissue  necrosis. 

What  are  the  physical  signs  ? 

The  uteras  is  usually  enlarged;  the  sound,  when  introduced, 
detects  great  irregularity  of  the  endometrium,  and  usually  causes 
bleeding.  If  the  curette  is  used,  a  grayish,  brain-like  material  is 
removed. 

With  what  are  sarcoma  and  carcinoma  of  the  body  of  the 
uterus  most  likely  to  be  confused,  and  how  is  the 
diagnosis  made  ? 

They  are  chiefly  to  be  confased  with  villous  endometritis,  sloughing 
polypi  or  retained  secundines.  The  diagnosis  is  made  by  removing 
fragments  with  the  curette,  knife  or  scissors,  and  subjecting  them  to 


SALPINGITIS.  177 

microscopical  examination.  Marked  anaemia  and  emaciation  would 
lead  one  to  suspect  malignant  disease,  yet  severe  endometritis  or  a 
vascular  polypus  may  cause  similar  symptoms. 

What  is  the  treatment  ? 

Hysterectomy  gives  us  the  only  prospect  of  cure. 

The  palhative  treatment  consists  in  curetting  and  applying  caustics 
to  thes  interior  of  the  uterus,  keeping  the  vagina  clean  with  anti- 
septic douches,  as  weak  creolin,  and  reheving  pain  with  opium. 


Salpingitis. 

What  is  the  pathology  ? 

In  salpingitis  there  is  usually  first  a  catarrhal  inflammation  of  the 
mucous  membrane  of  the  tube ;  this  extending  to  the  peritoneum 
sets  up  a  localized  peritonitis  which  usually  closes  the  fimbriated  ex- 
tremity, and  often  by  adhesions  distorts  the  tube.  From  the  closui  t 
of  the  outer  extremity  and  the  narrowing  of  the  lumen  in  dif- 
ferent places  by  the  traction  of  peritonitic  adhesions,  the  secretions 
are  retained  and  distend  the  tube.  This  distention  is  favored  by 
the  softening  arising  from  the  catarrhal  inflammation.  Other  por- 
tions of  the  tube  may  be  thickened,  partly  from  inflammation  of 
tbe  tube  itself  and  partly  from  the  neighboring  peritonitis.  In 
some  cases  the  obstruction  at  the  uterine  end  of  the  tube  is  over- 
come by  the  pressure  of  the  tubal  contents,  which  may  then  be 
expelled  into  the  uterus  and  vagina,  constituting  the  condition  called 
' '  salpingitis  profluens. ' ' 

The  varieties  of  salpingitis,  named  according  to  the  tubal  contents 

are — 

1.  Hydrosalpinx. 

2.  Hgematosalpinx. 

3.  Pyosalpinx. 

Tubercular  salpingitis  is  now  thought  to  occur  either  as  a  primary 
or  secondary  affection. 

What  is  the  etiology  of  salpingitis  ? 

It  usually  arises  from  an  extension  to  the  tube  of  an  inflammation 
12 


178  ESSENTIALS  OF  GYNECOLOGY. 

of  the  endometrium,  and  its  etiology  is  tliat  of  the  endometritis, 
especially — 

1.  Sepsis  during  parturition  or  abortion. 

2.  The  use  of  septic  instruments. 

3.  Gonorrhoea. 

What  are  the  characteristics  of  a  hydrosalpinx  ? 

In  a  hydrosalpinx  the  tube  is  distended  with  serum,  the  result  of 
a  catarrhal  inflammation.  The  softening  of  the  walls  easily  allows 
the  distention,  which  varies  in  position  according  to  the  traction  of 
peritonitic  adhesions. 

What  are  the  characteristics  of  a  haematosalpinx  ? 

Here  the  tube  is  distended  with  blood,  which  may  have  one  of 
three  sources  : — 

1.  It  most  often  occurs  as  a  result  of  a  tubal  pregnanc3\ 

2.  It  may  be  exuded  from  the  tubal  mucous  membrane  as  a  re- 
sult of  the  catarrhal  inflammation. 

3.  It  may  occur  as  an  extension  of  a  hsematometra  due  to  atresia 
of  vagina  or  cervix. 

The  tube  is  usually  first  hypertrophied,  later  thinned,  and  it  may 
rupture ;  this  accident  is  usually  delayed  by  peritonitic  thickening 
about  the  tube.     The  blood  is  generally  thick  and  tarry. 

What  are  the  characteristics  of  a  pyosalpinx  ? 

The  tube  is  usually  more  thickened  and  surrounded  by  more  peri- 
tonitic adhesions  than  is  hydrosalpinx. 

The  pus  may  be  slight  in  amount,  or  the  tube  may  be  immensely 
distended  with  very  fetid  pus. 

Adhesions  are  apt  to  form  between  tube  and  neighboring  viscera, 
and  the  pus  sometimes  ruptures  into  them,  especially  into  rectum  or 
bladder. 

What  are  the  symptoms  of  salpingitis  ? 

The  patient  usually  suffers  from  a  burning  and  dragging  pain  in 
the  region  of  the  affected  tube,  especially  on  standing  and  walking. 
Dysmenorrhoea  is  common ;  repeated  attacks  of  peritonitis  are  not 
infrequent.  In  the  case  of  pyosalpinx  septic  symptoms  may  be  pres- 
ent.    There  is  tenderness  on  pressure  in  the  lateral  vaginal  fornix, 


AFFECTIONS   OF  THE  OVARIES.  179 

and  on  making  a  bimanual  examination  an  elongated  cystic  mass  can 
usually  be  detected  at  the  side  of  the  uterus. 

What  are  the  results  of  salpingitis  ? 

A  hydrosalpinx  or  haematosalpinx  occasionally  subsides  so  as  to 
cause  few  symptoms ;  they  may  become  purulent  and  form  pyo- 
salpinx. 

A  hsematosalpinx  may  rupture  into  the  peritoneum  or  into  the 
broad  ligament,  forming  an  haematocele  in  the  former  case,  and  a 
haematoma  in  the  latter. 

A  pyosalpinx  if  unrelieved  by  operation  may  continue  for  years, 
producing  chronic  invalidism,  or  may  rupture  and  cause  septicaemia 
or  peritonitis. 

What  is  the  treatment  of  salpingitis  ? 

1.  Prophylactic. — Cleanliness  and  antisepsis  during  the  puerperium 
and  in  the  use  of  all  instruments. 

2.  PaUiative. — During  the  acute  stage  of  invasion,  rest  in  bed, 
poultices,  and,  if  much  pain  is  present,  allow  opium. 

When  the  case  becomes  subacute,  apply  counter  irritation  to  vaginal 
fornix  over  the  affected  tube  or  tubes,  and  employ  tampons  of  boric 
acid  and  glycerine  and  hot  water  vaginal  douches. 

3.  Radical. — If  the  distention  and  thickening  of  the  tube  fails  to 
subside  under  the  foregoing  treatment,  remove  the  tube  and  ovary 
of  the  side  affected.  Often  both  sides  are  involved  and  require 
removal. 


AflFections  of  the  Ovaries. 

Hemorrhage  into  the  Ovaries. 

What  is  the  etiology  and  pathology  ? 

Hemorrhage  into  the  ovary  is  caused  by  anything  producing  a  con- 
gestion of  the  organ,  such  as  obstruction  to  the  circulation,  pelvic 
diseases,  tumors,  disorganization  of  the  blood,  disease  of  heart  or 
lungs,  catching  cold  during  menstruation,  and  excessive  or  violent 
sexual  intercourse.    The  hemorrhage  maybe  either  follicular,  occur- 


180  ESSENTIALS   OF  GYNECOLOGY. 

ring  into  the  Graafian  follicles,  or  interstitial.  The  former  being  com- 
paratively frequent,  the  latter  rare.  The  ovary  is  usually  enlarged 
and  irregular  in  shape  and  more  sensitive  to  pressure  ;  the  follicles 
may  rupture  and  form  pelvic  haematocele  or  set  up  peritonitis. 

What  are  the  symptoms  ? 

Although  the  hyperaemia  of  the  ovary  may  be  suspected  from 
menorrhagia,  throbbing  pains  over  the  ovaries  and  their  acute 
enlargement,  no  positive  symptoms  are  produced  until  rupture 
occurs,  when,  according  to  the  amount  of  blood  poured  out,  they 
may  vary  from  symptoms  of  slight  pain  and  shock  to  those  of  fatal 
hemorrhage  and  collapse. 

What  is  the  treatment  ? 

While  hyperaemia  of  the  ovary  is  suspected,  regulate  the  mode  of 
Hfe  and  enjoin  rest  just  before  and  during  the  early  part  of  menstru- 
ation. Apply  counter-irritation  to  the  ovarian  region ;  attempt  to 
elevate  the  ovaries  by  soft  packing  if  they  are  prolapsed,  and 
administer  hot- water  vaginal  douches.  If  rupture  occurs,  the  treat- 
ment is  that  of  pelvic  peritonitis  or  haematocele. 

Ovaritis. 
What  is  the  pathology  ? 

Ovaritis  or  inflammation  of  the  ovary  may  be  acute  or  chronic. 

Tubercular  ovaritis  is  usually  described  separately. 

Acute  ovaritis  may  be  follicular  or  interstitial ;  the  two  are  often 
combined.  In  the  follicular  form,  the  epithelium  of  the  follicles 
degenerates,  the  liquor  folliculi  becomes  purulent,  and  the  ovum  is 
destroyed. 

In  the  interstitial  form,  the  stroma  is  infiltrated  with  serum  and 
leucocytes  and  the  connective  tissue  cells  are  increased ;  abscesses 
often  form  between  the  bundles  of  fibers ;  sometimes  gangrene 
occurs. 

Chronic  ovaritis,  often  the  result  of  the  acute,  may  exhibit  3 
forms — 

1.  The  atrophic. 

2.  The  hyperplastic. 

3.  The  cystic. 


AFFECTIONS   OF  THE   OVARIES.  181 

In  the  atrophic  form  the  ovary  is  small,  hard,  and  nodular ;  the 
tunica  albuginea  is  much  thickened. 

In  the  hyperplastic  form,  the  ovary  is  enlarged,  hard,  and  com- 
paratively smooth  ;  it  usually  prolapses  from  the  increased  weight. 

In  the  cystic  variety,  the  change  is  not  confined  to  the  follicles,  but 
the  stroma  is  involved  as  well. 

The  atrophic  form  may  be  present  in  one  part  of  the  ovary  and  the 
hyperplastic  in  another;  the  tunica  albuginea  is  thickened  and 
prevents  rupture  of  the  cysts.  Ovaries  the  seat  of  ovaritis  are 
often  more  or  less  surrounded  by  peritonitis. 

What  is  the  etiology  of  ovaritis  ? 

It  occasionally  occurs  in  severe  cases  of  the  infectious  diseases  or 
metalhc  poisoning,  but  is  most  often  secondary  to  disease  of  the 
tubes  or  peritoneum.  It  is  predisposed  to  by  anything  causing  con- 
gestion of  the  ovary,  such  as  displacement  of  the  uterus  or  ovary  or 
excessive  venery.  A  salpingitis  with  its  own  etiology  is  the  most 
frequent  cause  of  ovaritis.  Among  individual  causes,  the  following 
are  especially  to  be  mentioned  : — 

Sepsis  during  labor,  abortion  or  operations. 

Gonorrhoea. 

Catching  cold  during  menstruation. 

What  are  the  symptoms  ? 

The  symptoms  of  acute  ovaritis  are  usually  mingled  with  those 
of  the  accompanying  salpingitis  or  peritonitis.  There  is  generally 
sharp  pain  in  the  ovarian  region  or  regions,  radiating  to  the  back ; 
often  pain  in  micturition  and  defecation,  and  various  reflex  neuroses. 
If  an  abscess  forms,  septic  symptoms  may  be  present. 

In  the  chronic  form  the  symptoms  are  usually  less  marked ;  there 
is  dull  pain  in  the  ovarian  region,  increased  by  walking.  There  is 
dyspareunia  and,  especially  if  the  ovary  is  prolapsed,  painful  defe- 
cation. 

What  are  the  physical  signs  ? 

These  may  be  obscure,  from  the  fact  that  the  ovary  and  tube  are 
bound  together  by  peritonitic  adhesions  into  one  indistinct  mass. 

When  definable,  we  feel,  on  making  a  bimanual  examination,  a 
round  body  at  the  side  of  the  uterus,  but  separated  from  it  by  a 


182  ESSENTIALS   OF  GYNECOLOGY. 

slight  interval ;  it  is  sensitive  to  pressure,  producing  pain  of  a  sick- 
ening character ;  it  may  or  may  not  be  movable.  When  the  ovary 
is  prolapsed,  this  round,  tender  mass  may  be  felt  in  the  pouch  of 
Douglas. 

From  what  must  you  differentiate  an  inflamed  ovary  ? 

From —  Salpingitis. 

Peritonitic  deposit. 

Exudation  into  the  broad  ligament. 

Fibroid  tumor. 

Faeces  in  the  rectum. 

How  would  you  difierentiate  ovaritis  from  salpingitis  ? 

This  is  often  very  difficult,  from  the  fact  that  the  two  conditions 
frequently  coexist.  The  chief  features  in  the  differential  diagnosis 
are  found  in  the  physical  signs,  as  follows  : — 

Ovaritis  vs.  Salpingitis. 

Lies  farther  from  the  uterus ;      Lies  nearer  the   uterus ;    more 

more  globular  in  shape.  elongated. 

The  ovary  cannot  be  felt  else-      The  ovary  can  often  be  felt  sepa- 

where.  rate  from  the  mass. 

More  sensitive.  Less  sensitive. 

How  would  you  differentiate  an  ovaritis  from  an  exudation 
in  the  broad  ligament  ? 

Ovaritis  vs.  Exudation  in  Broad  Ligament. 

More  circumscribed.  Less  circumscribed. 

Less  closely  related  to  vaginal      More  closely  related  to  vaginal 

vault.  vault. 

Less  fixity  of  the  uterus.  More  fixity  of  the  uterus. 

How  would  you  differentiate  ovaritis  from  a  lateral  uterine 
fibroid  ? 

Ovaritis  vs.  Lateral  Fibroid. 

Sensitive  to  pressure.  Insensitive  to  pressure. 

Less  intimately  connected  with      More  intimately  connected  with 

the  uterus.  the  uterus ;  moves  with  it. 

Density  less.  Density  greater. 

Menorrhagia  less  common.  Menorrhagia  more  common. 


AFFECTIONS   OF  THE   OVARIES.  183 

How  would  you  differentiate  ovaritis  from  faeces  in  the 
rectum? 

Ovaritis  vs.                      Fceces. 

More  sensitive.  Less  sensitive. 

Grlobular.  Elongated  in  shape. 

Does  not  indent  on  pressure.  Indents  on  pressure. 

Found  after  emptying  rectum.  Disappears  on  emptying  rectum. 

What  is  the  treatment  of  ovaritis  ? 

During  the  acute  stage  keep  patient  quiet  in  bed ;  apply  hot 
poultices  to  the  lower  abdomen ;  keep  bowels  open  and  faeces  soft ; 
give  an  anodyne,  if  necessary.  Later,  apply  counter-irritation  by 
means  of  iodine  to  the  vaginal  fornix  over  the  affected  organ,  and 
support  the  ovary  with  a  tampon.  An  excellent  method  is  to  soak 
a  roll  of  gauze  in  a  solution  of  iodoform  1  part,  chloral  1  part,  and 
glycerine  4  parts,  and  place  this  about  the  cei-vix,  especially  on  the 
affected  side.  After  the  withdrawal  of  this  support,  which  may  be 
left  in  twelve  to  twenty-four  hours,  a  hot- water  vaginal  douche  may 
be  used  with  advantage. 

As  a  last  resort,  after  a  faithful  trial  of  the  above  palliative 
measures  for  months  without  avail,  and  if  the  patient  is  a  great 
sufferer,  removal  of  the  offending  organ  is  indicated. 

If  abscess  of  the  ovary  is  present,  early  operation  is  indicated. 

An  ovary  the  seat  of  ovaritis  is  usually  best  removed  through  the 
vagina. 

Prolapse  of  the  Ovary. 

What  is  the  etiology  and  pathology  ? 

Prolapse  of  the  ovary  may  occur  either  as  a  result  or  cause  of 
disease.  From  the  increase  in  size,  due  to  congestion  or  inflamma- 
tion, the  ovary  is  apt  to  prolapse. 

In  a  retroversion  or  retroflexion  of  the  uterus,  the  ovaries  also  are 
usually  drawn  backward,  and  from  their  disturbed  circulation  become 
congested  and  diseased.  In  their  descent  they  usually  first  lie  on 
the  retro-ovarian  shelves,  and  may  then  further  descend,  especially 
the  left,  into  the  pouch  of  Douglas. 

What  are  the  symptoms  ? 

They  are  those  of  ovai'itis  and  of  ovarian  compression  ;  the  latter 


184  ESSENTIALS   OP   GYNECOLOGY. 

being  most  marked,  viz.  :  painful  defecation  and  d3^sparennia.    (The 
differential  diagnosis  has  been  given  under  ovaritis.) 

What  is  the  treatment  ? 

{a)  Palliative. — If  due  to  a  displacement  of  the  uterus  and  both 
uterus  and  ovaries  are  movable,  replace  the  uterus  and  maintain  it  in 
position  by  means  of  a  pessary. 

When  the  ovary  alone  is  displaced,  if  movable,  support  it  at  first 
with  a  tampon  ;  later  a  pessary  may  perhaps  be  worn. 

When  the  ovary  is  fixed  by  adhesions,  an  attempt  should  be  made 
to  cause  resolution  of  the  adhesions  by  counter-irritation,  glycerine  or 
boroglyceride  tampons,  hot- water  douches  and  gentle  massage. 

(5)  Radical. — If  the  palliative  measures  fail  and  the  symptoms 
are  severe,  operation  is  indicated,  either  to  remove  the  prolapsed 
ovary,  or,  if  the  uterus  is  displaced  backward,  to  break  up  the  adhe- 
sions and  fasten  the  uterus  forward  by  hysterorrhaphy  or  by  short- 
ening the  round  ligaments. 

TiBIORS  OF  THE  OVARY. 

What  are  the  chief  varieties  ? 

{a)  Cysts.  (c)    Sarcomata. 

[h)   Carcinomata.  {d)  Fibromata. 

Tuberculosis  of  the  ovary  is  sometimes  described  under  tumors  of 
the  ovary. 

What  are  the  varieties  of  ovarian  cyst  ?    Describe  them. 

The  varieties  of  ovarian  cyst  are — 

The  simple  follicular. 

The  proliferating  glandular. 

The  proliferating  papillary. 

The  dermoid. 
The  simple  follicular  cyst  is  formed  by  distention  and  coalescence 
of  Graafian  follicles.     This  variety  of  cj^st  is  usually  small. 

The  proliferating  glandular  cyst,  or  ovarian  adenoma,  is  developed 
from  the  "glandular  or  germinal  epithelium,  either  before  or  sub- 
sequent to  the  formation  of  the  Graafian  follicles ' '  (Howell).  This  is 
the  ordinary  multilocular  cyst,  which  may  attain  a  large  size.    Within 


AFFECTIONS   OF  THE   OVARIES.  185 

one  main  cyst  there  ma}^  be  several  secondary'  or  daughter  cysts. 
The  fluid  is  viscid,  usually  greenish,  often  gelatinous. 

The  proliferating  papillary  cyst  is  developed  from  the  remains  of 
the  Wolffian  body  at  the  hilum  of  the  ovary.  On  the  interior  of  the 
cyst,  and  often  on  the  exterior,  are  papillae  or  warts  in  simple  or  com- 
pound form.  These  papillary  cysts  are  often  accompanied  by  ascites, 
often  infect  the  peritoneum,  and  may  become  malignant. 

The  dermoid  cyst  on  its  interior  seems  lined  with  skin.  It  may 
contain  hair,  sebaceous  matter,  teeth  or  irregular  fragments  of 
bone,  etc. 

The  present  accepted  idea  as  to  the  origin  of  dermoid  cysts  is  that 
they  are  caused  by  an  abnormal  inclusion  of  the  epiblast ;  i.  e. ,  that 
certain  misplaced  embryonic  cells  grow  within  the  ovary  and  produce 
the  tissue  to  which  they  were  destined. 

What  is  the  etiology  of  ovarian  cysts  ? 

Concerning  this  little  is  known.  They  occur  most  frequently  be- 
tween the  ages  of  20-50,  but  are  found  both  in  the  young  and  old. 

Simple  ovaritis  or  injury  of  the  ovary  are  said  by  some  to  predis- 
pose to  the  formation  of  a  cyst. 

What  changes  may  occur  in  an  ovarian  cyst? 
The  principal  changes  are  the  following  : — 

It  may  rupture,  usually  from  traumatism. 
Hemorrhage  may  occur  into  it. 
It  may  become  gangrenous  or  may  suppurate. 
The  hemorrhage,  gangrene  and  suppuration  are  usually  the  result 
of  torsion  of  the  pedicle. 

Suppuration  may  also  arise  from  the  introduction  of  sepsis  if  the 
tumor  is  tapped,  as  formerly  practiced. 

What  are  the  symptoms  of  an  ovarian  cyst  ? 

They  are  chiefly  those  of  pressure.  There  may  be  difficulty  in  urina- 
tion and  defecation  ;  in  the  later  stages  the  patient  is  greatly  ex- 
hausted by  the  great  weight,  and  often  suff'ers  with  dyspnoea. 

What  are  the  physical  signs  of  an  ovarian  cyst  ? 

These  vary  with  the  location.  When  small  and  in  the  pelvis  we 
get  a  tense  elastic  mass,  usually  fluctuating  and  insensitive  to  pres- 
sure. The  multilocular  variety  may  seem  hard.  The  utems  is  dis- 
placed by  the  tumor. 


186  ESSENTIALS   OF  GYNECOLOGY. 

When  the  cyst  has  extended  to  the  abdomen,  we  get  distention  of 
the  abdomen  and  dullness  on  percussion  over  the  tumor.  Fluctua- 
tion can  usually  be  detected. 

From  what  must  you  differentiate  an  ovarian  cyst  when 
small  and  situated  in  the  pelvis  ? 

From  (a)  Distended  tube. 

(5)  Peritonitic  exudation. 

(c)  Inflammatory  exudation  into  broad  ligament. 

(d)  Extra-uterine  gestation. 

How  would  you  differentiate  a  small  ovarian  cyst  from  a  dis- 
tended tube  ? 

Ovarian  Cyst  vs.  Distended  Tube. 

No  inflammatory  history;  gradual      History  of  acute  inflammation; 

development ;  little  if  any  pain.  pain  usually  prominent. 

More  globular.  More  elongated. 

Less  intimately  connected  with      More  intimately  connected  with 

the  uterus.  the  uterus. 

Insensitive  to  pressure.  Sensitive  to  pressure. 

Less  fixity.  More  fixity. 

How  would  you  differentiate  a  small  ovarian  cyst  from  a  peri- 
tonitic exudation  ? 

Ovarian  Cyst  vs.         Peritonitic  Exvdation. 

No  history  of  acute  inflammation.       History  of  acute  inflammation. 
Insensitive.  Sensitive  to  pressure. 

More  mobile.  Fixed. 

More  lateral.  Usually  in  pouch  of  Douglas. 

How  would  you  differentiate  a  small  ovarian  cyst  from  an  in- 
flammatory exudation  into  the  broad  ligament  ? 

Ovarian  Cyst  vs.      Inflammatory  Exudation, 

Absence  of  history  of  inflamma-      History  of  inflammation  follow- 
tion.  ing  labor,  abortion,  or  opera- 

tion. If  a  haematoma,  history 
of  sharp  pain,  shock,  perhaps 
symptoms  of  hemorrhage. 


AFFECTION*   OF  THE   OVARIES. 


187 


More  mobile. 

Induration  of  parametrium  want- 
ing. 
Insensitive. 
Bulges  less  into  vagina. 


Fixed. 
Induration  present. 

Sensitive  to  pressure. 
Bulges  more  into  vagina. 


How  would  you  diflferentiate  an  ovarian  cyst  from  an  extra- 
uterine pregnancy  ? 

Extra-uterine  Pregnancy. 


Ovarian  Cyst 
Slow  growth. 
No  symptoms  of  pregnancy. 

Menstruation    usually    not    far 

from  normal. 
More  mobile. 

Uterus  usually  not  enlarged. 
Pain   only   from    pressure ;    no 

acute  attacks. 


vs. 


G-rowth  more  rapid. 

Constitutional  symptoms  of  preg- 
nancy. 

Amenorrboea  usually  followed  by 
menorrhagia. 

More  fixed. 

Uterus  enlarged. 

Attacks  of  pain  ;  finally  a  severe 
attack,  symptoms  of  shock  and 
hemorrhaofe. 


From  what  must  you  differentiate  a  large   ovarian  cyst 
occupying  the  abdomen? 

From  (a)  Pregnancy. 
(6)  Ascites. 

(c)  Fibroid  tumor  of  the  uterus. 
{d)  Distended  bladder, 
(e)  Haematometra. 


How  would  you  differentiate 
pregnant  uterus  ? 

Ovarian  Cyst 
More  lateral. 
Menstraation  continues. 
Positive  symptoms  of  pregnancy 

absent. 
Uterus    small,    separate    from 

tumor;  cervix  not  softened. 
Fluctuating. 


a  large  ovarian  cyst  from  a 

vs.  Pregnant  Uterus. 

More  central. 
Amenorrboea  the  rule. 
Positive  symptoms  of  pregnancy 

present. 
Uterus  forms  the  tumor  ;  cervix 

softened. 
Less    fluctuating ;    foetal    parts 

felt. 


188  .  ESSENTIALS   OF   GYNECOLOGY. 

Intermittent  contractions  absent.    Intermittent  contractions  present. 
Grrowth  less  rapid.  Growth  more  rapid. 

How  would  you  differentiate  a  large  ovarian  cyst  from 
ascites  ? 

Ovarian  Cyst  vs.                      Ascites. 

Patient  on  back  : —  Patient  on  back  : — 

Swelling  central  or  unilateral.  Swelling  bilateral. 

Dullness  in  front.  Tympanitic  in  front. 

Tympanitic  on  the  sides.  Dullness  on  the  sides. 

Percussion  note  varies  little  on      Percussion  note  varies  greatly  in 

turning  patient  from  side  to          turning  from  side  to  side. 

side. 

Circumscribed.  DiiFuse. 

How  would  you  differentiate  a  large  ovarian  cyst  from  a 
large  fibroid  tumor  of  the  uterus  ? 

Ovarian  Cyst  vs.  Fibroid. 

Fluctuating.  Firm,  non-fluctuating. 

Less  intimately  connected  with      More  intimately  connected  with 

the  uterus.  the  uterus ;  moves  with  it. 

Menorrhagia  uncommon.  Menorrhagia  common. 

Uteras  usually  not  enlarged.  Uteras  usually  enlarged. 

How  would  you  differentiate  a  large  ovarian  cyst  from  a 
distended  bladder  ? 

Ovaiian  Cyst                vs.  Distended  Bladder. 

More  lateral.  Central. 

Enlargement  slow.  Enlargement  rapid. 

Remains  after  patient  is  cathe-  Disappears    when     patient     is 

terized.  catheterized. 

How  would  you  differentiate  a  large  ovarian  cyst  from  a 
hsematometra  ? 

Ovarian  Cyst  vs.  Hcematmnetra. 

Menstnial  flow  appears.  Menstrual  blood  retained. 

More  lateral;  separate  from  the      Central;  tumor  formed  by  the 

uterus.  distended  uterus. 

Pain  only  from  pressure.  Periodical  attacks  of  pain,  due  to 

increase  of  contents. 


AFFECTIONS   OF  THE   OVARIES.  189 

Atresia  absent.  Atresia    of   vagina    or    cervix 

present. 

What  is  the  treatment  of  an  ovarian  cyst? 

The  only  treatment  is  removal.  If  large,  through  abdominal 
coeliotomy ;  if  small  it  can  easily  be  removed  through  the  vagina. 

Parovarian  Cysts. 
Describe  briefly. 

They  are  cysts  developed  in  the  broad  ligament  from  the  parova- 
rium, the  remains  of  the  Wolffian  body.  These  cysts  are  usually 
unilocular ;  the  contents  colorless,  thin  and  watery.  The  cyst  wall 
is  usually  thin,  and  fluctuation  very  distinct.  As  the  cyst  grows,  it 
opens  up  the  folds  of  the  broad  ligament. 
What  is  the  treatment  ? 

Removal  by  coeliotomy  is  the  best  treatment.  The  broad  ligament, 
which  is  spread  out  over  the  tumor,  is  incised  near  to  and  parallel  to 
the  tube,  and  the  tumor  is  enucleated  from  its  bed^  The  cavity  in 
the  broad  ligament  is  then  either  closed  so  as  to  leave  no  pockets,  or 
the  edges  of  the  broad  ligament  are  brought  to  and  stitched  in  the 
lower  angle  of  the  abdominal  wound  and  the  cavity  drained.  The 
former  practice  is  usually  preferable. 

What  are  the  chief  points  in  the  technique  of  an  abdominal 
coeliotomy  for  the  removal  of  the  uterine  appendages 
or  a  cyst? 

Have  the  bowels  of  the  patient  thoroughly  emptied  and  let  her 
take  a  thorough  warm  bath.  On  the  evening  before  the  operation, 
place  upon  the  abdomen  a  towel  soaked  in  a  solution  of  soft  soap  to 
be  left  until  the  following  morning.  On  the  day  of  the  operation, 
the  abdomen  and  pubes  are  shaved,  scrubbed  with  soap  and  water, 
washed  with  alcohol,  and  then  with  bichloride  1-1000. 

All  antiseptic  precautions  must  be  observed  in  regard  to  instru- 
ments, hands,  sponges,  etc. 

The  patient  having  been  anaesthetized,  a  final  cleansing  of  the 
abdomen  with  alcohol  and  bichloride  is  performed.  An  incision, 
about  three  inches  long,  is  made  in  the  median  line,  beginning  just 
belov/  the  umbilicus ;  this  incision  is  deepened  to  the  peritoneum 
and  bleeding  points  are  clamped.  The  peritoneum  is  raised  with 
thumb  forceps,  one  held  by  the  operator,  the  other  by  an  assistant, 


190 


ESSENTIALS   OF  GYNECOLOGY. 


and  the  peritoneum  cut  between  the  forceps ;  the  incision  is  length- 
ened with  the  scissors,  cutting  on  the  finger  to  the  length  of  the 
abdominal  wound.     The  latter  may  be  lengthened,  if  necessary. 

If  the  operation  is  for  the  removal  of  the  appendages,  the  fundus 
of  the  uterus  is  felt  for  as  a  landmark ;  the  ovary  and  tube  of  the 
affected  side  are  brought  into  the  abdominal  wound  and  surrounded 
by  warm  sponges  or  pads.  The  broad  ligament  is  tied  in  section 
beneath  the  appendage  and  the  parts  outside  the  ligature  cut  away, 
leaving  just  enough  to  prevent  the  ligature  from  slipping.  The  liga- 
ture is  then  cut  short  and  the  stump  dropped  back  into  the  abdom- 
inal cavity.     The  other  side  is  treated,  if  necessary,  in  the  same  way. 

If  the  operation  is  for  an  ovarian  cyst,  after  opening  the  abdomen 
the  cyst  is  punctured  with  a  trocar,  the  emptied  sac  drawn  out  of 
the  abdominal  wound,  the  adhesions  separated,  if  necessary,  the 
pedicle  tied,  and  the  stump  treated  as  before.  If  pus  has  gotten 
into  the  abdominal  cavity,  the  latter  is  freely  irrigated  with  warm 
sterilized  salt  solution ;  drainage  may  or  may  not  be  indicated. 

The  abdominal  wound  is  closed  by  one  of  several  methods.  A 
very  good  one  is  to  use  silkworm  gut,  passing  through  skin,  muscle, 
fascia  and  peritoneum,  suture  the  fascia  with  catgut  and  then  after 
tying  the  deep  sutures  bring  the  skin  into  apposition  by  sutures  of 
silkworm  gut  introduced  between  them.  Some  suture  the  perito- 
neum separately,  but  this  is  unnecessary.  The  wound  is  then 
cleansed,  a  sterile  dressing  is  applied  and  held  in  place  by  plaster 
strips  and  an  abdominal  binder  and  the  patient  is  transferred  to  bed. 
The  bed  should  be  warmed  with  hot-water  bottles,  but  great  care 
should  be  taken  that  the  patient  is  not  burned  by  them. 

How  is  the  Staffordshire  knot  tied  ? 

The  suture  is  passed  from  you  through 
the  centre  of  the  pedicle  by  means  of  an 
aneurism  needle,  and  the .  needle  with- 
drawn ;  the  loop  is  then  brought  forward 
over  the  tumor,  one  end  of  the  suture 
brought  above  and  the  other  left  below 
it  (see  Fig.  59).  The  two  ends  are  now 
tied  in  a  double  knot,  then  passed  around 
the  pedicle  in  the  crease  formed  by  the 
loop  and  tied  in  a  double  knot  on  the 


Fig.  59. 


Staffobdshire  Knot  (Taii). 

This  shows  knot  after  loop  has 
been  brought  over,  one  end 
brought  above  it,  and  the 
first  turn  of  the  artery  knot 
made. 


AFFECTIONS   OF  THE   OVARIES.  191 

other  side.  This  suture  was  formerly  much  used,  but  now,  unless 
the  pedicle  is  very  small,  it  is  thought  better  to  ligate  it  in  smaller 
sections. 

What  is  the  after  treatment  of  the  case  ? 

The  patient  receives  no  food  by  the  mouth  for  12-24  hours,  nutri- 
ent enemata  being  used  in  the  meantime.  The  urine  is  drawn  with 
a  catheter.  As  little  opium  as  possible  is  used.  The  bowels  are 
moved  on  the  third  day  by  a  turpentine  enema,  calomel  gr.  iv  (gr.  j 
every  half  hour)  or  salines.  If  tympanites  occurs  at  any  time,  the 
bowels  are  moved 

The  stitches  are  removed  on  the  7-8 th  day,  and  the  patient  is 
allowed  up  on  the  14th-21st. 

Describe  the  vaginal  operation  for  the  removal  of  a  diseased 
appendage  or  an  ovarian  cyst. 

The  same  preliminary  preparations  are  observed  as  for  an  abdom- 
inal coeliotomy.  At  the  time  of  the  operation  the  vulva  and  vagina 
are  thoroughly  disinfected,  the  patient  being  in  the  lithotomy  posi- 
tion and  on  a  Kelly's  pad.  The  perineum  is  retracted  with  a  spec- 
ulum. If  endometritis  is  present  the  uterus  is  first  curetted.  The 
posterior  lip  of  the  cervix  is  then  seized  with  a  volsella  and  drawn 
forward.  The  vagina  is  grasped  with  a  toothed  thumb-forceps  about 
where  it  joins  the  rectum,  and  drawn  downward.  Between  this 
point  and  the  junction  of  vagina  and  cervix  a  cut  is  made  with  scis- 
sors directed  toward  the  uterus ;  first  going  through  the  vagina, 
then  into  the  pouch  of  Douglas.  This  incision  may  be  enlarged 
laterally.  Two  fingers  are  inserted  into  this  opening  and  the  pelvic 
contents  examined.  If  a  diseased  tube  and  ovary  are  found,  a  gauze 
pad  or  sponge,  each  with  a  long  silk  attached,  is  inserted  above  the 
mass  to  be  removed,  to  keep  back  intestines  or  omentum ;  the  ap- 
pendage is  freed,  brought  down  into  the  vagina,  ligated  and  re- 
moved. The  gauze  pad  or  sponge  is  now  removed  and  the  vaginal 
opening  may  either  be  closed  or  the  pelvic  cavity  may  be  drained 
with  gauze,  according  to  the  indications.  If  an  ovarian  cyst  is 
to  be  removed,  after  opening  the  pouch  of  Douglas  the  cyst  is 
tapped  and  emptied  ;  the  sac  drawn  down  into  the  vagina,  ligated, 
and  removed. 


192 


ESSENTIALS   OF   GYNiECOLOGY. 


What  are  the  advantages  of  the  vaginal  over  the  abdominal 
operation  ? 

In  the  vaginal  operation  the  shock  is  less,  the  convalescence  is 
usually  smoother  and  more  rapid,  and  the  abdominal  cicatrix  with 
its  tendency  to  hernia  is  avoided. 


Fig.  60. 


Dowd's  Apparatus  for  Sterilizing  Catgut. 

What  are  the  indications  for  a  vaginal  operation  ? 

Pus  tubes,  ovarian  abscesses,  small  ovarian  cysts,  small  fibro- 
myomata,  and  malignant  disease  of  the  uterus.  In  the  last-named 
condition  hysterectomy  is  performed.    In  the  case  of  fibro-myomata, 


AFFECTIONS   OF  THE   OVARIES.  193 

either  the  tumor  may  be  enucleated  (myomectomy),  or  the  uterus 
may  be  removed  entire  or  by  morcellation. 

How  would  you  prepare  catgut  for  ordinary  ligature  and 
suture  ? 

One  of  the  best  methods  is  that  by  means  of  boiling  alcohol. 
This  is  conveniently  carried  out  by  Dowd's  apparatus  a  cut  of 
which  is  here  given.  It  consists  of  a  coil  of  block  tin  tubing  en- 
cased in  a  copper  cylinder.  The  lower  end  of  the  coil  is  straight- 
ened out  and  projects  through  the  rubber  cork  of  the  jar  in  which 
the  bottles  of  catgut  are  to  be  sterilized.  The  upper  end  of  the 
coil  is  bent  into  a  convenient  shape  for  suspension  and  during  use 
is  closed  with  a  cotton  plug.  On  one  side  of  the  cylinder  are  two 
taps,  the  lower  for  the  entrance,  the  upper  for  the  exit  of  cold 
water  from  a  faucet  which  condenses  the  alcoholic  vapor  which 
rises  in  the  coil. 

The  catgut,  wound  on  glass  spools,  is  placed  in  small  bottles  (pre- 
ferably with  screw  tops)  which  are  filled  with  strong  alcohol.  These 
bottles  are  placed  in  the  large  jar  and  covered  with  strong  alcohol. 
The  jar  is  then  attached  to  the  condenser,  and  placed  in  a  vessel  of 
water  on  a  gas  or  other  stove.      The  boiling  is  kept  up  for  an  hour. 

Another  good  method  is  the  following  : — 

1.  Soak  the  gut  in  ether  for  1  hour. 

2.  Wipe  with  a  bichloride  towel. 

3.  Soak  in  bichloride  1  :  1000  for  8  hours. 

4.  Wipe  with  a  bichloride  towel. 

5.  Store  it  in  absolute  alcohol. 

How  would  you  prepare  the  chromicized  (McEwen's)  catgut? 
Soak  the  gut  for  48  hours  in  the  following  solution  : — 
R.     Acidi  chromici,  ^iij-^vss 

Aquae,  q.  s.  ad    Oj 

M.  et  adde 

Glycerini,  Ov. 

Then  store  the  gut  in  carbolized  glycerine  1-5. 
Wipe  with  a  bichloride  towel  before  using. 


194  ESSENTIALS   OF   GYNECOLOGY. 

Ectopic  Gestation. 

Ectopic  gestation  may  be  considered  as  primarily  tubal.  Three 
varieties  are  recognized : 

1.  Tubal  proper,  (free  tubal). 

2.  Tubo-uterine,  (interstitial) ;  in  that  portion  of  the  tube  em- 
braced by  the  uterine  wall. 

3.  Tubo-ovarian. — Between  the  tube  and  the  ovary. 
Abdominal  pregnancy  was  probably  originally  tubal.      Ovarian 

pregnancy  rarely  if  ever  occurs.     Tait  says  that  he  never  saw  a 
case. 

What  is  the  etiology  ? 

Disease  of  the  tube,  or  obstruction  of  its  lumen  by  tumors, 
pressure,  or  traction  are  regarded  as  the  chief  causes. 

What  are  the  symptoms  ? 

There  is  usually  a  history  of  previous  sterility  ;  then  symptoms  of 
early  pregnancy ;  usually  amenorrhoea  at  first,  later  irregular 
menstruation  or  menorrhagia.  Attacks  of  pain  with  symptoms  of 
shock  may  be  present ;  then  when  the  sac  ruptures,  symptoms  of 
hemorrhage,  severe  shock  and  collapse. 

What  are  the  physical  signs  ? 

Before  rupture  occurs,  the  uterus  is  felt  to  be  enlarged  and  soft- 
ened, and  at  the  side  is  found  a  mass  formed  by  the  distended  tube. 

At  the  time  of  rupture,  if  it  has  occurred  with  hemorrhage  into 
the  peritoneal  cavity,  very  few  physical  signs  may  be  present ;  simply 
an  indistinct  feeling  of  fluid  in  the  pouch  of  Douglas.  Later,  as 
the  blood  coagulates,  a  tumor  is  formed  behind  the  uterus. 

If  the  rupture  has  occurred  into  the  broad  ligament,  a  tumor  is 
formed  at  once  by  the  blood-distended  ligament.  This  tumor  pushes 
the  uterus  forward  and  toward  the  opposite  side.  It  tends  to  bulge 
into  the  vagina,  and  a  finger  introduced  into  the  rectum  detects 
a  narrowing  of  it. 

What  is  the  course  and  result  ? 

Ectopic  gestation  is  usually,  if  not  always,  primarily  tubal.     At 

about  the  third  month,  either  a  rupture  of  the  tubal  wall  may  occur, 

*  with  the  escape  of  the  foetal  products,  or  the  escape  may  take  place 


ECTOPIC   GESTATION,  195 

tlirough  the  fimbriated  extremity,  constituting  a  tubal  abortion. 
When  a  rupture  of  the  tubal  wall  occurs,  it  may  take  place  1.  through 
a  portion  covered  by  peritoneum,  /.  e.  into  the  peritoneal  cavity,  or 
2.  through  a  portion  not  covered  by  peritoneum  /.  e.  down  between 
the  folds  of  the  broad  ligament.  The  intraperitoneal  rupture  is 
apt  to  prove  fatal,  although  often  not  until  several  hemorrhages 
have  occurred.  In  an  extraperitoneal  rupture  the  hemorrhage  is 
usually  limited.  The  foetus  usually  dies  when  it  escapes  from  the 
tube.  When  the  rupture,  however,  is  extraperitoneal  /.  e.  between 
the  folds  of  the  broad  ligament,  the  foetus  may  survive  and  go  to 
term. 

When  the  blood  effusion  is  small  it  may  be  absorbed.    Sometimes 
suppuration  occurs. 

From  what  must  you  differentiate  extra-uterine  pregnancy  ? 

Suppurative  cellulitis. 
Fibroid  tumor. 
Ovarian  cyst. 
Dermoid  cyst. 
Parovarian  cyst. 
Salpingitis. 
Retroversio-flexio. 

What  is  the  treatment  ? 

If  a  diagnosis  is  made  before  rupture  occurs,  the  best  treatment 
consists  in  the  removal  of  the  tube  with  its  contents.  At  the  time 
of  rupture,  if  this  has  taken  place  into  the  peritoneal  cavity,  open 
the  abdomen,  ligate  and  remove  the  sac  from  which  the  hemorrhage 
comes,  also  the  foetal  remains  and  blood  clots.  Drainage  is  rarely 
necessary,  unless  the  foetal  sac  has  become  infected. 

If  the  rupture  has  taken  place  into  the  broad  ligament  and  the 
resulting  h^^matoma  is  small,  this  may  be  left  with  the  hope  of  its 
absorption.  If  repeated  hemorrhages  occur,  surgical  interference 
is  indicated.  If  suppuration  take  place,  the  mass  should  be  opened 
from  the  vagina  and  drained. 

If  the  life  of  the  foetus  continues  after  the  rupture,  and  the  case 
is  seen  during  the  early  months,  the  life  of  the  foetus  should  be 
disregarded  in  the  interest  of  the  mother.  The  foetus  and  mem- 
branes should  be  removed  and  the  sac  drained.     11'  the  case  is  first 


196 


ESSENTIALS   OF   GYNECOLOGY. 


seen  after  the  viability  of  the  foetus,  an  attempt  should  be  made  to 
save  both  lives. 

Fistulse. 

What  are  the  cMef  varieties  met  with  in  gynaecology  ? 

Thej^  ma}'  be  either  uriuaiy  or  fecal. 

Urinary  fistul^e  present  the  following  varieties  (see  Fig.  61)  :— 

1.  Urethro-vaginal. 

2.  Yesico-vaginal. 

3.  Yesico-uterine. 
4  Uretero-vaginal. 
5.  Uretero-uterine. 


Fig.  61. 


To  REPRESENT   THE   CHIEF    VARIETIES   OF  URINARY    FiSTULA — URETHRO-VAGINaI  , 

Vesico-vagtnal  and  Vesico-uterine. — Those  with  the  ureters  are  not  seen. 
The  seat  of  a  recto-vaginal  fistula  is  indicated  (i>e  Slnety). 

The  most  common  is  the  vesico-vaginal. 

The  fecal  fistula  which  especially  concerns  us  is  the  recto-vaginal. 

What  is  the  etiology  of  a  vesico-vaginal  fistula  ? 

The  most  common  cause  is  sloughing  following  long-continued 
pressure,  usually  in  parturition,  but  occasionally  from  a  pessary.  It 
may  be  produced  by  direct  laceration  through  the  septum.  It  is  pre- 
disposed to  by  the  causes  of  a  tedious  labor. 


FISTULA.  197 

What  are  the  symptoms  ? 

The  involuntary  escape  of  urine. 

A  urinous  odor  about  the  person. 

Irritation  and  excoriation  of  the  vulva  and  parts  around. 

How  is  the  diagnosis  made  ? 

If  the  fistula  is  not  evident  on  exposing  the  parts  with  a  Sims' 
speculum,  the  patient  being  in  Sims'  position,  the  bladder  may  be 
distended  with  some  colored  antiseptic  fluid,  like  creolin  solution, 
and  by  the  exit  of  the  latter  the  fistula  may  be  detected,  and  then 
verified  by  a  probe. 

What  is  the  treatment? 

The  treatment  usually  pursued  in  this  country  is  the  operation  of 
Sims,  which  is  performed  as  follows :  The  patient  is  anaesthetized, 
an  antiseptic  vagi-nal  douche  given,  and  all  antiseptic  precautions 
observed  during  the  operation.  She  is  placed  in  Sims'  position 
and  Sims'  speculum  introduced.  The  edges  of  the  fistula  are  pared 
with  the  knife  or  scissors,  the  mucous  membrane  not  being  included 
in  the  incision.  Silkworm-gut  or  silver-wire  sutures  are  then  intro- 
duced, about  one-fifth  to  one-fourth  inch  apart,  not  penetrating  the 
mucous  membrane.  The  parts  are  brought  into  apposition  by  tying 
or  twisting  the  sutures,  and  then  a  self-retaining  catheter  is  intro- 
duced. The  sutures  are  left  for  eight  days.  The  operation  for 
a  urethro- vaginal  fistula  is  similar  to  the  above. 

What  are  the  chief  steps  in  the  operation  for  the  cure  of  a 
vesico-uterine  fistula  ? 

Emmet  regards  the  condition  as  due  to  a  laceration  of  the  cervix 
extending  into  the  bladder,  the  laceration  healing  only  below.  The 
operation  is  based  on  this  idea,  viz. :  The  cervix  is  split  up  to  the 
fistula ;  the  edges  of  the  latter  are  denuded,  and  the  whole  brought 
together  in  a  manner  similar  to  a  trachelorrhaphy,  especial  care  being 
taken  with  the  ujjper  sutures. 


198  ESSENTIALS   OF   GYNECOLOGY. 

Recto- vaginal  Fistula. 

What  is  the  etiology  ? 

This,  like  the  vesico- vaginal  fistula,  is  usually  due  to  sloughing 
caused  by  long-continued  pressure  in  parturition,  or  may  be  produced 
by  laceration  through  the  septum,  either  by  the  unaided  efforts  of 
nature  or  by  instramental  delivery.  Cancer  or  syphilis  may,  of 
course,  cause  fistula,  but  this  will  not  concern  us  here. 

What  is  the  treatment  ? 

It  is  similar  to  Sims'  operation  for  vesico-vaginal  fistula.  The 
edges  are  denuded  and  brought  together  by  silkworm  gut  or  silver 
wire,  the  rectal  mucous  membrane  being  uninjured.  If  the  fistula 
is  near  the  vulva,  it  is  usually  best  to  divide  the  sphincter  ani  and 
perineum  up  to  the  fistula,  to  dissect  this  out,  and  then  close  the 
parts  as  in  a  laceration  of  the  perineum  through  the  sphincter  ani. 


INDEX. 


ALEXANDER'S  operation,  123 
Ameiiorrhaoe,  96 
Anterior  colporrliaphy,  132,  137 
Atrophy  of  the  uterus,  155 

BIMANUAL  examination,  45 
Bladder,  35 
Bulbi  vestibuli,  20 

CARCINOMA  uteri,  173 
Catgut,  preparation  of,  193 
Cellulitis,  pelvic,  88 
Clitoris,  18 
Coccygodynia,  79 
Condylomata,  pointed,  75 

syphilitic,  76 
Curette,  62,  63 

DEVELOPMENT    of   the    pelvic 
organs,  42 
Dilators,  58 
elastic,  62 
graduated,  hard,  60 
Displacements  of  the  uterus,  110 
anteflexion,  112 
anteversion.  111 
retroversion   and    retroflexion, 
115 
Dysmenorrboea,  99 

ECZEMA  of  the  vulva,  73 
Emmet's  operation,  130 
Endometritis,  145 
acute,  145 
chronic,  146 
Erythema  of  the  vulva,  73 
Ectopic  gestation,  194 

r^ALLOPIAN  tubes,  30 

r      Fibroid  tumors  of  tlie  uterus, 

155 
Fistula,  recto- vaginal,  198 


Fistulfe,  196 

Fossa  navicularis,  20 

Fourchette,  20 

HEMATOCELE  and  hsematoma, 
pelvic,  92 
Hgematocele,  pudendal,  71 
Hemorrhage  from  vulva,  72 
Hernia,  pudendal,  70 
Hymen,  21 

Hypersesthesia  of  the  vulva,  78 
Hypertrophy  of  the  cervix,  138 
Hysterectomy,  162  • 

vaginal,  175 
Hysterorrbaphy,  124 

INSTRUMENTS,  47 
JL     Inversion  of  the  uterus,  164 
Irritable  urethral  caruncle,  80 
Ischio-rectal  fossa,  41 

LABIA  majora;  17 
minora,  18 
Laceration  of  the  perineum,  128 
of  the  cervix,  140 

l/TALFORMATIONS  of  the  uterus. 

Malformations  of  the  vagina,  104 
atresia  of  the  vagina,  104 
of  the  vulva,  81 
Menstruation,  96 
disorders  of,  96 
amenorrbcea,  96 
dysmenorrhffia,  99 
obstructive,  100 
congestive,  100 
neuralgic,  101 
ovarian,  102 
membranous,  102 
menorrbagia  and  metrorrhagia, 
98 

199 


200 


INDEX. 


Menstruation,  vicarious,  98 
Metritis,  150 

acute,  151 

chronic,  152 
Mons  veneris,  17 
Myomectomy,  162 

lU'EW  growths  of  the  vulva,  75 

OVAEIES,  31 
affections  of,  179 
hemorrhage  into,  179 
prolapse  of,  183 
tumors  of,  184 
Ovaritis,  180 

PAPILLOMATA,  simple,  75 
Parovarian  cysts,  189 

Parovarium,  34 

Pelvic  floor,  39 

Perineal  body,  40 

Perineum,  muscles  of,  41 

Peritoneufu,  pelvic,  85 

Peritonitis,  pelvic,  86 

Pessaries,  119 

Physical  examination  of  pelvic  or- 
gans, 42 

Polypi,  169 

Probe,  uterine,  58 

Prolapse  of  urethral  mucous  mem- 
brane, 81 

Prolapsus  uteri,  125 

Pruritus  vulvae,  76 

Pudendal  heematocele,  71 
hernia,  70 

RECTAL  examination,  46 
Eectum,  37 
Eound   ligaments,  intra-abdominal 
shortening  of,  125 

SAENGEE-TAIT  operation,  132 
Salpingitis,  177 


Sarcoma  of  the  uterus,  176 

Skin  diseases  of  the  vulva,  73 

Sound,  uterine,  54 

Specula,  47 

Brewer's  speculum,  52 
Fergusson's  speculum,  50 
Kelly's  speculum,  52 
Simon's  speculum,  50 
Sims'  speculum,  48 

Stenosis  of  the  cervix,  140 

TENTS,  58 
Trachelorrhaphy,  143 

UEINAEY  tract,  34 
Uterus,  23 
Uterus,  mucous  membrane  of,  25 
vagino-fixation  of,  125 


YAGINA,  21 
V      diseases  of,  82 
Vaginal  examination,  43 
Vaginismus,  78 
Vaginitis, 

simple  catarrhal,  82 

gonorrhoeal,  83 

ulcerative,  84 

diphtheritic,  85 
Vestibule,  20 

Vicarious  menstruation,  98 
Volsella,  53 

Vulva,  malformations  of,  81 
Vulvitis,  63 

acute  simple  catarrhal,  64 

chronic  catarrhal,  64 

gonorrhceal,  65 

phlegmonous,  66 

diphtheritic,  67 

gangrenous,  67 

follicular,  68 
Vulvo-vaginal  glands,  21 

cyst  and  abscess  of,  69 


Medical  and  Surgical  Works 


PUBLISHED   BY 


W.  B.  SAUNDERS,  925  Walnut  Street,  Philadelphia,  Pa. 


PAGE 

American  Pocket  Medical  Dictionary    .    .  31 
^American  Text-Book  of    Applied    Thera- 
peutics     6 

*American  Text-Book  of  Chemistry  ...  40 
*American  Text-Book  of  Diagnosis  ...  40 
*American  Text-Book  of  Dis.  of  Children  .  11 
*An  American  Text-Book  of  Diseases  of  the 

Eye,  Ear,  Nose,  and  Throat 13 

*An    American  Text-Book  of  Genito-Uri- 

nary  and  Skin   Diseases 12 

*American  Text-Book  of  Gynecology  .  .  .10 
*American  Text-Book  of  Legal  Medicine  .  40 

American  Text-Book  of  Nursing 40 

*American  Text-Book  of  Obstetrics  ...  7 
*American  Text  Book  of  Pathology  .  .  .  40 
*American  Text-Book  of  Physiology  ...  5 
*American  Text-Book  of  Practice  ....  8 
*American  Text-Book  of  Surgery  ...  9 
Anders' Theory  and  Practice  of  Medicine  .  17 

Ashton's  Obstetrics 39 

Atlas  of  Skin  Diseases 24 

Ball's  Bacteriology 39 

Bastin's  Laboratory  Exercises  in  Botany  .  32 
Beck's  Surgical  Asepsis    ...        .....  37 

Boisliniere's  Obstetric  Accidents 35 

Brockway's  Physics 39 

Burr's  Nervous  Diseases 37 

Butler's  Materia  Medica  and  Therapeutics  -^o 
Cerna's  Notes  on  the  Newer  Remedies  .  .  28 
Chapin's  Compendium  of  Insanity  ....  31 
Chapman's  Medical  Jurisprudence  .  .  .  .  37 
Church  and  Peterson's  Nervous  and  Men- 
tal Diseases 15 

Clarkson's  Histolo^^y 29 

Cohen  and  Eshner's  Diagnosis 39 

Corwin's  Diagnosis  of  the  Thorax   ....  33 

Cragin's  Gjmsecology 39 

Crookshank's  Text-Book  of  Bacteriology  .  23 

DaCosta's  Manual  of  Surgery 19 

De  Schweinitz's  Diseases  of  the  Eye  ...  25 
Dorland's  Pocket  Medical  Dictionary    .    .  31 

Doriand's  Obstetrics      37 

Frothingham's  Bacteriological  Guide  ...  26 

Garrigues'  Diseases  of  Women 30 

Gleason's  Diseases  of  the  Ear 39 

*Gould  and  Pyle's  Curiosities  of  IMedicine  .  15 

Grafstrom's  Massage 24 

Griffith's  Care  of  the  Baby  .    .        34 

Griffith's  Infant's  Weight  Chart 35 

Gross's  Autobiography 22 

Hampton's  Nursing 35 

Hare's  Physiology 39 

Hart's  Diet  in  Sickness  and  in  Health    .    .  32 

Haynes'  Manual  of  Anatomy 37 

Heisler's  Embryology 40 

Hirst's  Obstetrics 16 

Holmes'   Manual  of  Surgery 40 

Hyde's  Syphilis  and  Venereal  Diseases  .  .  37 
Internaiioiial  Text-Book  of  Surgery    .    .    .40 

lackson's  Diseases  of  the  Eye 40 

Jackson  and  Gleason's  Diseases  of  the  Eye, 

Nose,  and  Throat 39 

Keating's  Pronouncing  Dictionary  ....  22 

Keatiiig's  Lif':  Insurance 35 

K';en's  (Jpera  ion  Blanks 32 

Keen's  Surgery  of  'J'yphoid  Fever  .    .    ,    ,  18 


PAGE 

Kyle's  Diseases  of  Nose  and  Throat  ...  40 

Laine's  Temperature  Charts 28 

Lockwood's  Practice  of  Medicine    ....  37 

Long's  Syllabus  of  Gj'necology 30 

Macdonald's  Surgical  Diagnosis  and   ircat- 

ment 18 

McFarland's  Pathogenic  B.icteria  ....  26 
Mallory  and  Wright's   Pathological    1  ech- 

nique 18 

Martin's  Surgery 39 

Martin's  Minor  Surgery,  Bandaging,  and 

Venereal  Diseases 39 

Meigs'  Feeding  in  Early  Infancy 26 

Moore's  Orthopedic  Surgery 19 

Morris'  Materia  Medica  and  Iherapeuiics  39 

Morris'  Practice  of  Medicine 39 

Morten's  Nurses'  Dictionary 34 

Nancrede's  Anatomy  and  Dissection  ...  27 

Nancrede's  Anatomy ...  39 

Nancrede's  Principles  of  Surgery  ....  40 
Norris'  Syllabus  of  Obstetrical  Lectures    .  33 

Ogden's  Urinary  Analysis 40 

Penrose's  Diseases  of  Women 20 

Powell's  Diseases  of  Children 39 

Pryor's  Pelvic  Inflammations 40 

Pye's  Bandaging  and  Surgical  Dressing    .  19 

Raymond's  Physiology 37 

Rowland's  Clinical  Skiagraphy 29 

Saundby's  Renal  and  Urinary  Diseases  .    .  21 
*Saunders'  American  Year-Book  of  Medi- 
cine and  Surgery 14 

Saunders'  Medical  Hand-Atlases  .  .  .  .  3,  4 
Saunders'  Pocket  ]\Iedical  Formulary  .  .  31 
Saunders'  New  Series  of  Manuals  .  .  .  36,  37 
Saunders'  Series  of  Question  Compends  38,  39 

Sayre's  Practice  of  Pharmacy 39 

Semple's  Pathology  and  Morbid  Anatomy  39 
Semple's  Legal  Medicine.  'Toxicology,  and 

Hygiene 39 

Senn's  Genito-L'^rinary  Tuberculosis    ...  20 

Senn's  Tumors 21 

Senn's  Syllabus  of  Lectures  on  Surgery  .  .  33 
Shaw's  Nervous  Diseases  and  Insanity  .    .  39 

Starr's  Diet-Lists  for  Children 34 

Stehvagon's  Diseases  of  the  Skin 39 

Stengel's  Pathology 16 

Stevens'  Materia  Medica  and  Therap.  utics  28 

Stevens'  Practice  of  Medicine 27 

Stewart's  Manual  of  Physiology  .    .        ■    ■  33 
Stewart    and    Lawrance's    Medical    Elec- 
tricity      39 

Stoney's  Materia  Medica  for  Nurses  ...  40 
Stoney's  Practical  Points  in  Nursing  ...  23 
Sutton  and  Giles'  Diseases  of  Women  .  25,37 
Thomas's  Diet-List  and  Sick-Room   Diet- 
ary   34 

Thornton's  Dose-Book  and  Manual  of  Pre- 
scription-Writing    37 

Thresh's  Water  and  Water  Supplies  ...  29 
Van  Valzah  and   Nisbet's  Diseases  of  the 

Stomach 17 

Vecki's  Sexual  Impotence 29 

Vierordt  and  Stuart's  Medical  DiagU'  sis    .  24 

Warren's  Surgical  Pathology 21 

Wolff's  Chemistry 39 

Wolff's  Examination  of  Urine 3Q 


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In  ordering,  be  careful  to  state  the  style  of  binding  desired — 
Cloth,  Sheep,  or  Half  Morocco. 


Special  Offer.  To  physicians  of  approved  credit  who   furnish   satisfactory 

Monthly  references  books  will  be  sent  express  prepaid ;  terms,  f5.00  cash 
Payment  upon  delivery  of  books,  and  monthly  payments  of  $5  00  thereafter 
Flan.  until  full  amount  is  paid.  Any  of  the  publications  of  W.  B.  Saunders 

(100  titles  to  select  from)  may  be  had  in  this  way  at  catalogue  price, 
including  the  American  Text-Book  Series,  the  Medical  Hand- 
Atlases,  etc.  All  payments  to  be  made  by  mail  or  otherwise,  free 
of  all  expense  to  us, 


SAUNDERS" 

MEDICAL  HAND-ATLASES. 


The  series  of  books  included  under  this  title  consists  of  authorized  translations 
into  English  of  the  world-famous  Lehmann  Medicinische  Handatlanten, 
which  for  scientific  accuracy,  pictorial  beauty,  compactness,  and  cheap- 
ness surpass  any  similar  volume?  ever  published. 

Each  volume  contains  from  50  to  100  colored  plates,  executed  by  the 
most  skilful  German  lithographers,  besides  numerous  illustrations  in  the  text. 
There  is  a  full  and  appropriate  description,  and  each  book  contains  a  con- 
densed but  adequate  outline  of  the  subject  to  which  it  is  devoted. 

One  of  the  most  valuable  features  of  these  aliases  is  that  they  offer  a  ready 
and  satisfactory  substitute  for  clinical  observation.  Such  observation, 
of  course,  is  available  only  to  the  residents  in  large  medical  centers ;  and  even 
then  the  requisite  variety  is  seen  only  after  long  years  of  routine  hospital  work. 
To  those  unable  to  attend  important  clinics  these  books  will  be  absolutely  indis- 
pensable, as  presenting  in  a  complete  and  convenient  form  the  most  accurate  re- 
productions of  clinical  work,  interpreted  by  the  most  competent  of  clinical  teachers. 

While  appreciating  the  value  of  such  colored  plates,  the  profession  has 
heretofore  been  practically  debarred  from  purchasing  similar  works  because  of 
their  extremely  high  price,  made  necessary  by  a  limited  sale  and  an  enormous 
expense  of  production.  In  planning  this  series,  however,  arrangements  were 
made  with  representative  publishers  in  the  chief  medical  centers  of  the  world 
for  the  publication  of  translations  of  the  atlases  into  nine  different  languages, 
the  lithographic  plates  for  all  being  made  in  Germany,  where  work  of  this  kind 
has  been  brought  to  the  greatest  perfection.  The  enormous  expense  of  making 
the  plates  being  shared  by  the  various  publishers,  the  cost  to  each  one  was 
reduced  to  practically  one-tenth.  Thus  by  reason  of  their  universal  transla- 
tion and  reproduction,  affording  international  distribution,  the  publishers  have 
been  enabled  to  secure  for  these  atlases  the  best  artistic  and  professional 
talent,  to  produce  them  in  the  most  elegant  style,  and  yet  to  offer  them  at  a 
price  heretofore  unapproached  in  cheapness.  The  great  success  of  the 
undertnkin'j  is  demonstrated  by  the  fact  that  the  volumes  have  already  appeared 
in  nine  different  languages — German,  English,  French,  Italian,  Russian, 
vSpanish,   Danish,   Swedish,   and    Hungarian. 

In  view  of  the  unprecedented  success  of  these  works,  Mr.  Saunders  has  con- 
tracted with  the  publisher  of  the  original  German  edition  for  one  hundred 
thousand  copies  of  the  atlases.  In  consideration  of  this  enormous  under- 
taking, the  luiblisher  has  been  enabled  to  prepare  and  furnish  special  additional 
colored  plates,  making  the  series  even  handsomer  and  more  complete  than 
was  originally  intended. 

As  an  indication  of  the  great  practical  value  of  the  atlases  and  of  the 
immense  favor  with  wliich  they  have  been  received,  it  should  be  noted  that  the 
Medical  Department  of  the  U.  S.  Army  has  adopted  the  "  Atlas  of  Opera- 
tive Surgery"  as  its  standard,  and  has  ordered  the  book  in  large  quantities  for 
distribution  to  the  various  regiments  and  army  posts. 

The  same  careful  and  competent  editorial  supervision  has  been  secured  in 
the  English  edition  as  in  the  originals.  The  translations  have  been  edited  by 
the  leading  American  specialists  in  the  different  subjects.  The  volumes  are 
of  a  uniform  and  Cf^nvenicnt  size  ($  X  lYz  inches),  and  are  substantially  bound. 

(/'<?;-  List  of  Volumes  in  this  Series,  see  next  page.) 
3 


SAUNDERS'  MEDICAL  HAND-ATLASES. 


VOLUMES  NOW  READY. 

Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.    By  Dr.  Chr. 

Jakob,  of  Erlangen.     Edited  by  Augustus  A.  Eshner,  M.  D.^  Professor 

of  Clinical  Medicine  in  the  Philadelphia  Polyclinic;   Attending  Physician 

to  the  Philadelphia  Hospital.     68  colored  plates,  and  64  illustrations  in  the 

text.     Cloth,  I3.00  net. 

"  The  charm  of  the  book  is  its  clearness,  conciseness,  and  the  accuracy  and  beauty  of  its 
illustrations.  It  deals  with  facts.  It  vividly  illustrates  those  facts.  It  is  a  scientific  work 
put  together  for  ready  reference." — Brooklyn  Medical  Jourtial. 

Atlas  of  Legal  Medicine.  By  Dr.  E.  R.  von  Hofmann,  of  Vienna.  Edited 
by  Frederick  Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases, 
Woman's  Medical  College,  New  York  ;  Chief  of  Clinic,  Nervous  Dept., 
College  of  Physicians  and  Surgeons,  New  York.  With  120  colored  figures 
on  56  plates,  and  193  beautiful  half-tone  illustrations.     Cloth,  ^3.50  net. 

"  Hofmann's  'Atlas  of  Legal  Medicine'  is  a  unique  work.  This  immense  field  finds  in  this 
book  a  pictorial  presentation  that  far  excels  anything  with  which  we  are  familiar  in  any  other 
work . " — Philadelphia  Medical  Journal. 

Atlas  of  Diseases  of  the  Larynx.  By  Dr.  L.  Grunwald,  of  Munich. 
Edited  by  Charles  P.  Grayson,  M.  D.,  Lecturer  on  Laryngology  and 
Rhinology  in  the  University  of  Pennsylvania ;  Physician-in-Charge,  Throat 
and  Nose  Department,  Hospital  of  the  University  of  Pennsylvania.  With 
107  colored  figures  on  44  plates,  and  25  text-illustrations.    Cloth,  ^2.50  net. 

"Aided  as  it  is  by  magnificently  executed  illustrations  in  color,  it  cannot  fail  of  being  of 
the  greatest  advantage  to  students,  general  practitioners,  and  expert  laryngologists."— 5/". 
Louis  Medical  and  Surgical  Journal. 

Atlas  of  Operative  Surgery.  By  Dr.  O.  Zuckerkandl,  of  Vienna.  Edited 
by  J.  Chalmers  DaCosta,  M.'D.,  Clinical  Professor  of  Surgery,  Jefferson 
Medical  College,  Philadelphia  ;  Surgeon  to  the  Philadelphia  Hospital.  With 
24  colored  plates  and  217  text  illustrations.      Cloth,  ^3.00  net. 

"  We  know  of  no  other  work  vhat  combines  such  a  wealth  of  beautiful  illustrations  with 
clearness  and  conciseness  of  language,  that  is  so  entirely  abreast  of  the  latest  achievements, 
and  so  useful  both  for  the  beginner  and  for  one  who  wishes  to  increase  his  knowledge  of  oper- 
ative surgery." — Miinchener  Medicinische    Wochenschrift. 

Atlas  of  Syphilis  and  the  Venereal  Diseases.  By  Prof.  Dr.  Franz 
Mracek,  of  Vienna.  Edited  by  L.  Bolton  Bangs,  M.  D.,  late  Professor 
of  Genito-Urinary  and  Venereal  Diseases,  New  York  Post-Graduate  Medi- 
cal School  and  Hospital.  With  71  colored  plates  from  original  water-colors, 
and  16  black-and-white  illustrations.      Cloth,  $3.50  net. 

"A  glance  through  the  book  is  almost  like  actual  attendance  upon  a  famous  clinic." — 
Journal  of  the  American  Medical  Association. 

IN  PREPARATION. 
Atlas  of  External  Diseases  of  the  Eye.     By  Dr.  O.  Haar,  of  Zurich. 
Edited  by  G.   E.   de  Schweinitz,   M.  D.,    Professor  of  Ophthalmology, 
Jefferson  Medical  College,  Philadelphia.     With   100  colored  illustrations. 

Atlas  of  Skin  Diseases.  By  Prof.  Dr.  Franz  Mracek,  of  Vienna. 
Edited  by  Henry  W.  Stelwagon,  M.  D.,  Clinical  Professor  of  Derma^ 
tology,  Jefferson  Medical  College,  Philadelphia.     With  80  colored  plates. 

Atlas  of  Pathological  Histology,  Atlas  of  Operative  Gynecology, 

Atlas  of  Orthopedic  Surgery,  Atlas  of  Psychiatry. 

Atlas  of  General  Surgery.  Atlas  of  Diseases  of  the  Ear. 

4 


CATALOGUE    OF  MElDICAL    WORKS. 


5 


*AN  AMERICAN  TEXT-BOOK  OF  PHYSIOLOGY.  Edited  by 
William  H.  Howell,  Ph.D.,  M.  D.,  Professor  of  Physiology  in  the 
Johns  Hopkins  University,  Baltimore,  Md.  One  handsome  octavo  volume 
of  1052  pages,  fully  illustrated.  Prices  :  Cloth,  ^6.00  net;  Sheep  or  Half- 
Morocco,  ^7.00  net. 

This  work  is  the  most  notable  attempt  yet  made  in  America  to  combine  in 
one  volume  the  entire  subject  of  Human  Physiology  by  well-known  teachers 
who  have  given  especial  study  to  that  part  of  the  subject  upon  which  they  write. 
The  completed  work  represents  the  present  status  of  the  science  of  Physiology, 
particularly  from  the  standpoint  of  the  student  of  medicine  and  of  the  medical 
practitioner. 

The  collaboration  of  several  teachers  in  the  preparation  of  an  elementary  text- 
book of  physiology  is  unusual,  the  almost  invariable  rule  heretofore  having  been 
for  a  single  author  to  write  the  entire  book.  One  of  the  advantages  to  be  derived 
from  this  collaboration  method  is  that  the  more  limited  literature  necessary  for 
consultation  by  each  author  has  enabled  him  to  base  his  elementary  account 
upon  a  comprehensive  knowledge  of  the  subject  assigned  to  him;  another,  and 
perhaps  the  most  important,  advantage  is  that  the  student  gains  the  point  of  view 
of  a  number  of  teachers.  In  a  measure  he  reaps  the  same  benefit  as  would  be 
obtained  by  following  courses  of  instruction  under  different  teachers.  The 
different  standpoints  assumed,  and  the  differences  in  emphasis  laid  upon  the 
various  lines  of  procedure,  chemical,  physical,  and  anatomical,  should  give  the 
student  a  better  insight  into  the  methods  of  the  science  as  it  exists  to-day.  The 
work  will  also  be  found  useful  to  many  medical  practitioners  who  may  wish  to 
keep  in  touch  with  the  development  of  modern  physiology. 

CO?«  TRIBUTORS : 


HENRY  P.  BOWDITCH,  M.  D., 

Professor  of  Physiology,  Harvard  Medi- 
cal School. 

JOHN  G.  CURTIS,  M.  D., 

Professor  of  Physiology,  Columbia  Uni- 
versity, N.  Y.  (College  of  Physicians 
and  Surgeons). 

HENRY  H.  DONALDSON,  Ph.  D., 

Head-Professor  of  Neurology,  Univer- 
sity of  Chicago. 

W.  H.  HOWELL,  Ph.D.,  M.  D., 

Professor  of  Physiology,  Johns  Hopkins 
Universitj'. 

FREDERIC  S.  LEE,  Ph.  D., 

Adjunct  Professor  of  Physiology,  Colum- 
bia University,  N.  Y.  (College  of 
Physicians  and  Surgeons). 


WARREN  P.  LOMBARD,  M.D., 

Professor   of  Physiology,  University  of 
Michigan. 

GRAHAM  LUSK,  Ph.  D., 

Professor  of  Physiology,   Yale   Medica' 
School. 

W.  T.  PORTER,  M.D., 

Assistant  Professor  of  Physiology,  Har- 
vard Medical  School. 

EDWARD  T.  REICHERT,  M.D., 

Professor  of  Physiology,  University  of 
Pennsylvania. 

HENRY  SEW  ALL,  Ph.D.,  M.  D.. 

Professorof  Physiology,  Medical  Depart- 
ment, University  of  Denver. 


"  We  can  commend  it  most  heartily,  not  only  to  all  students  of  physiology,  but  to  every 
physician  and  pathologist,  as  a  valuable  and  comprehensive  work  of  reference,  written  by 
men  who  are  of  eminent  authority  in  their  own  special  %Viti\itz\.%."  —  London  Lancet. 

"  To  the  practitioner  of  medicine  and  to  the  advanced  student  this  volume  constitutes, 
we  believe,  the  best  expjosition  of  the  present  stitus  of  the  science  of  physiology  in  the  Eng- 
lish language." — American  yournal  of  the  Medical  Sciences. 


W.   B.    SAUNDERS' 


^AN  AMERICAN  TEXT-BOOK  OF  APPLIED  THERAPEU- 
TICS. For  the  Use  of  Practitioners  and  Students.  Edited  by 
James  C.  Wilson,  M.  D.,  Professor  of  the  Practice  of  Medicine  and  of 
Clinical  Medicine  in  the  Jefferson  Medical  College.  One  handsome  octavo 
volume  of  1326  pages.  Illustrated.  Prices:  Cloth,  ^7.00  net;  Sheep  or 
Half-Morocco,  ^8.00  net. 

The  arrangement  of  this  volume  has  been  based,  so  far  as  possible,  upon 
modern  pathologic  doctrines,  beginning  with  the  intoxications,  and  following 
with  infections,  diseases  due  to  internal  parasites,  diseases  of  undetermined 
origin,  and  finally  the  disorders  of  the  several  bodily  systems — digestive,  re- 
spiratory, circulatory,  renal,  nervous,  and  cutaneous.  It  was  thought  proper  to 
include  also  a  consideration  of  the  disorders  of  pregnancy. 

The  articles,  with  two  exceptions,  are  the  contributions  of  American  writers. 
Written  from  the  standpoint  of  the  practitioner,  the  aim  of  the  work  is  to  facili- 
tate the  application  of  l<nowledge  to  the  prevention,  the  cure,  and  the  allevia- 
tion of  disease.  The  endeavor  throughout  has  been  to  conform  to  the  title  of 
the  book — Applied  Therapeutics — to  indicate  the  course  of  treatment  to  be 
pursued  at  the  bedside,  rather  than  to  name  a  list  of  drugs  that  have  been  used 
at  one  time  or  another. 

The  list  of  contributors  comprises  the  names  of  many  who  have  acquired  dis- 
tinction as  practitioners  and  teachers  of  practice,  of  clinical  medicine,  and  of 
the  specialties. 

CONTRIBUTORS : 


Dr.  I.  E.  Atkinson,  Baltimore,  Md. 
Sanger  Brown,  Chicago,  III. 
John  B.  Chapin,  Philadelphia,  Pa. 
William  C.  Dabney,  Charlottesville,  Va. 
John  Chalmers  DaCosta,  Philada.,  Pa. 
I.  N.  Danforth,  Chicago,  111. 
John  L.  Dawson,  Jr.,  Charleston,  S.  C. 
F.  X.  Dercum,  Philadelphia,  Pa. 
George  Dock,  Ann  Arbor,  Mich. 
Robert  T.  Edes,  Jamaica  Plain,  Mass. 
Augustus  A.  Eshner,  Philadelphia,  Pa. 
J.  T.  Eskridge,  Denver,  Col. 
F.  Forchheimer,  Cincinnati,  O. 
Carl  Frese,  Philadelphia,  Pa. 
Edwin  E.  Graham,  Philadelphia,  Pa. 
John  Guiteras,  Philadelphia,  Pa. 
Frederick  P.  Henry,  Philadelphia,  Pa. 
Guy  Hinsdale,  Philadelphia,  Pa. 
Orville  Horwitz,  Philadelphia,  Pa. 
W.  W.  Johnston,  Washington,  D.  C. 
Ernest  Laplace,  Philadelphia,  Pa. 
A.  Laveran,  Pans,  France. 

"As  a  work  either  for  study  or  reference  it  will  be  of  great  value  to  the  practitioner,  as 
it  is  virtually  an  exposition  of  such  clinical  therapeutics  as  experience  has  taught  to  be  of 
the  most  value.  Taking  it  all  in  all,  no  recent  publication  on  therapeutics  can  be  compared 
with  this  one  in  practical  value  to  the  working  physician."  —  Chicago  Clinical  Review. 

"The  whole  field  of  medicine  has  been  well  covered.  The  work  is  thoroughly  practical, 
and  while  it  is  intended  for  practitioners  and  students,  it  is  abetter  book  for  the  general 
practitioner  than  for  the  student.  The  young  practitioner  especially  will  find  it  extremely 
suggestive  and  helpfiil," — The  Indian  Lancet, 


Dr.  James  Hendrie  Lloyd,  Philadelphia,  Pa. 
John  Noland  Mackenzie,  Baltimore,  Md. 
J.  W.  McLaughlin,  Austin,  Texas. 
A.  Lawrence  Mason,  Boston,  Mass. 
Charles  K.  Mills,  Philadelphia,  Pa. 
John  K.  Mitchell,  Philadelphia,  Pa. 
W.  P.  Northrup,  New  York  City. 
William  Osier,  Baltimore,  Md. 
Frederick  A.  Packard,  Philadelphia,  Pa. 
Theophilus  Parvin,  Philadelphia,  Pa. 
Beaven  Rake,  London,  England. 
E.  O.  Shakespeare,  Philadelphia,  Pa. 
Wharton  Sinkler,  Philadelphia,  Pa. 
Louis  Starr,  Philadelphia,  Pa. 
Henry  W.  Stelwagon,  Philadelphia,  Pa. 
James  Stewart,  Montreal,  Canada. 
Charles  G.  Stockton,  Buffalo,  N.  Y. 
James  Tyson,  Philadelphia,  Pa. 
Victor  C.  Vaughan,  Ann  Arbor,  Mich. 
James  T.  Whittaker,  Cincinnati,  O. 
J.  C.  Wilson,  Philadelphia,  Pa. 


CATALOGUE    OF  MEDICAL    WORKS. 


*AN  AMERICAN  TEXT-BOOK  OF  OBSTETRICS.  Edited  by 
Richard  C.  Norris,  M.  D.  ;  Art  Editor,  Robert  L.  Dickinson,  M.  D. 
One  handsome  octavo  volume  of  over  looo  pages,  vi^ith  nearly  900  colored 
and  half-tone  illustrations.  Prices:  Cloth,  ^7.00;  Sheep  or  Half-Morocco, 
$8.00. 

The  advent  of  each  successive  volume  of  the  series  of  the  American  Text- 
BoOKS  has  been  signalized  by  the  most  flattering  comment  from  both  the  Press 
and  the  Profession.  The  high  consideration  received  by  these  text-books,  and 
their  attainment  to  an  authoritative  position  in  current  medical  literature,  have 
been  matters  of  deep  international  interest,  which  finds  its  fullest  expression  in 
the  demand  for  these  publications  from  all  parts  of  the  civilized  vv^orld. 

In  the  preparation  of  the  "American  Text-Book  of  Obstetrics"  the 
editor  has  called  to  his  aid  proficient  collaborators  whose  professional  prominence 
entitles  them  to  recognition,  and  whose  disquisitions  exemplify  Practical 
Obstetrics.  While  these  writers  were  each  assigned  special  themes  for  dis- 
cussion, the  correlation  of  the  subject-matter  is,  nevertheless,  such  as  ensures 
logical  connection  in  treatment,  the  deductions  of  which  thoroughly  represent 
the  latest  advances  in  the  science,  and  which  elucidate  the  best  modern  methods 
of  procedure. 

The  more  conspicuous  feature  of  the  treatise  is  its  wealth  of  illustrative 
matter.  The  production  of  the  illustrations  had  been  in  progress  for  several 
years,  under  the  personal  supervision  of  Robert  L.  Dickinson,  M.  D.,  to  whose 
artistic  judgment  and  professional  experience  is  due  the  most  sumptuously 
illustrated  work  of  the  period.  By  means  of  the  photographic  art,  combined 
with  the  skill  of  the  artist  and  draughtsman,  conventional  illustration  is  super- 
seded by  rational  methods  of  delineation. 

Furthermore,  the  volume  is  a  revelation  as  to  the  possibilities  that  may  be 
reached  in  mechanical  execution,  through  the  unsparing  hand  of  its  publisher. 


CONTRIBUTORS : 


Dr.  James  C.  Cameron. 
Edward  P.  Davis. 
Robert  L.  Dickinson. 
Charles  Warrington  Earle. 
James  H.  Etheridge. 
Henry  J.  Garrigues. 
Barton  Cooke  Hirst. 
Charles  Jewett. 


Dr.  Howard  A.  Kelly. 
Richard  C.  Norris. 
Chauncey  D.  Palmer. 
Theophiliis  Parvin. 
George  A.  Piersol. 
Edward  Reynolds. 
Henry  Schwarz. 


"At  first  glance  we  are  overwhelmed  by  the  magnitude  of  this  work  in  several  respects, 
viz. :  First,  by  the  size  of  the  volume,  then  by  the  array  of  eminent  teachers  in  this  depart- 
ment who  have  taken  part  in  its  production,  then  by  the  profuseness  and  character  of  the 
illustrations,  and  last,  but  not  least,  the  conciseness  and  clearness  with  which  the  text  is  ren- 
dered. This  is  an  entirely  new  composition,  embodying  the  highest  knowledge  of  the  art  as 
it  stands  to-day  by  authors  who  occupy  the  front  rank  in  their  specialty,  and  there  are  many 
of  tliem.  We  cannot  turn  over  these  pages  without  being  struck  by  the  superb  illustrations 
which  adorn  so  many  of  them.  We  are  confident  that  this  most  practical  work  will  find 
instant  appreciation  by  practitioners  as  well  as  students." — New  York  Medical  Times. 

Permit  me  to  say  that  your  American  Text-Book  of  Obstetrics  is  the  most  magnificent 
medical  work  that  1  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work 
which  alone  is  sufficient  to  place  you  first  in  the  ranks  of  medical  publishers. 

With  profound  respect  I  am  sincerely  yours,  Alex.  J.  C.  Skene. 


8 


W.   B.   SAUNDERS' 


*AN  AMERICAN  TEXT-BOOK  OF  THE  THEORY  AND 
PRACTICE  OF  MEDICINE.  By  American  Teachers.  Edited 
by  William  Pepper,  M.  D.,  LL.D.,  Provost  and  Professor  of  the  Theory 
and  Practice  of  Medicine  and  of  Clinical  Medicine  in  the  University  of 
Pennsylvania.  Complete  in  two  handsome  royal- octavo  volumes  of  about 
looo  pages  each,  w^ith  illustrations  to  elucidate  the  text  wherever  necessary. 
Price  per  Volume :  Cloth,  ^5.00  net;  Sheep  or  Half-Morocco,  ;^6.oo  net. 


VOIiUME  I.  COWTAIXS: 


Hygiene. — Fevers  (Ephemeral,  Simple  Con- 
tinued, Typhus,  Typhoid,  Epidemic  Cerebro- 
spinal Meningitis,  and  Relapsing). — Scarla- 
tina, Measles,  Rotheln,  Variola,  Varioloid, 
Vaccinia, Varicella,  Mumps, Whooping-cough, 
Anthrax,  Hydrophobia,  Trichinosis,  Actino- 


mycosis, Glanders,  and  Tetanus. — Tubercu- 
losis, Scrofula,  Syphilis,  Diphtheria,  Erysipe- 
las, Malaria,  Cholera,  and  Yellow  Fever. — 
Nervous,  Muscular,  and  Mental  Diseases  etc. 


VOL.UME   II.  CONTAINS: 


Urine  (Chemistry  and  Microscopy). — Kid- 
ney and  Lungs. — Air-passages  (Larynx  and 
Bronchi)  and  Pleura. — Pharynx,  QEsophagus, 
Stomach  and  Intestines  (including  Intestinal 
Parasites),  Heart,  Aorta,  Arteries  and  Veins. 


— Peritoneum,  Liver, and  Pancreas. — Diathet- 
ic Diseases  (Rheumatism,  Rheumatoid  Ar- 
thritis, Gout,  Lithsemia,  and  Diabetes.) — 
Blood  and  Spleen. — Inflammation,  Embolism, 
Thrombosis,  Fever,  and  Bacteriology. 


The  articles  are  not  written  as  though  addressed  to  students  in  lectures,  but 
are  exhaustive  descriptions  of  diseases,  with  the  newest  facts  as  regards  Causa- 
tion, Symptomatology,  Diagnosis,  Prognosis,  and  Treatment,  including  a  large 
number  of  approved  formulae.  The  recent  advances  made  in  the  study 
of  the  bacterial  origin  of  various  diseases  are  fully  described,  as  well  as  the 
bearing  of  the  knowledge  so  gained  upon  prevention  and  cure.  The  subjects 
of  Bacteriology  as  a  whole  and  of  Immunity  are  fully  considered  in  a  separate 
section. 

Methods  of  diagnosis  are  given  the  most  minute  and  careful  attention,  thus 
enabling  the  reader  to  learn  the  very  latest  methods  of  investigation  without 
consulting  works  specially  devoted  to  the  subject. 


CONTRIBUTORS : 


J.  S.  Billings,  Philadelphia. 
Francis  Delafield,  New  York. 
Reginald  H.  Fitz,  Boston. 
James  W.  Holland,  Philadelphia. 
Henry  M.  Lyman,  Chicago. 
William  Osier,  Baltimore. 


Dr.  William  Pepper,  Philadelphia. 
W.  Giiman  Thompson,  New  York. 
W.  H.  Welch,  Baltimore. 
James  T.  Whittaker,  Cincinnati. 
James  C.  Wilson,  Philadelphia. 
Horatio  C.  Wood,  Philadelphia. 


"  We  reviewed  the  first  volume  of  this  work,  and  said :  '  It  is  undoubtedly  one  of  the  best 
text-books  on  the  practice  of  medicine  which  we  possess.*  A  consideration  of  the  second 
«.nd  last  volume  leads  us  to  modify  that  verdict  and  to  say  that  the  completed  work  is,  in  our 
opinion,  the  best  of  its  kind  it  has  ever  been  our  fortune  to  see.  It  is  complete,  thorough, 
accurate,  and  clear.  It  is  well  written,  well  arranged,  well  printed,  well  illustrated,  and  well 
bound.    It  is  a  model  of  what  the  modern  text-book  should  be." — New  York  Medical  yournal. 

'*  A  libiary  upon  modern  medical  art.  The  work  must  promote  the  wider  diffusion  of 
sound  knowledge." — American  Lancet. 

"  A  trusty  counsellor  for  the  practitioner  or  senior  student,  on  which  he  may  implicitly 
rely." — Edinburgh  Medical  jfournal. 


CATALOGUE    OF  MEDICAL    WORKS. 


*  AN  AMERICAN  TEXT-BOOK  OF  SURGERY.     Edited  by  Wil- 
liam W.  Keen,  M.D.,  LL.D.,  and  J.  William  White,  M.  D.,  Ph.  D, 

Forming  one  handsome  royal-octavo  volume  of  1250  pages  (10x7  inches), 
with  500  wood-cuts  in  text,  and  37  colored  and  half-tone  plates,  many  of 
them  engraved  from  original  photographs  and  drawings  furnished  by  the 
authors.     Prices  :  Cloth,  ^7.00  net;  Sheep  or  Half-Morocco,  ^8.00  net. 

SECOND  EDITION,  REVISED  AND  ENLARGED, 
With  a  Section  devoted  to  "  The  Use  of  the  Rbntgen  Rays  in  Surgery." 

The  want  of  a  text-book  which  could  be  used  by  the  practitioner  and  at  the 
same  time  be  recommended  to  the  medical  student  has  been  deeply  felt,  espe- 
cially by  teachers  of  surgery;  hence,  when  it  was  suggested  to  a  number  of 
these  that  it  would  be  well  to  unite  in  preparing  a  text-book  of  this  description, 
great  unanimity  of  opinion  was  found  to  exist,  and  the  gentlemen  below  named 
gladly  consented  to  join  in  its  production.  While  there  is  no  distinctive  Amer- 
ican Surgery,  yet  America  has  contributed  very  largely  to  the  progress  of  modem 
surgery,  and  among  the  foremost  of  those  who  have  aided  in  developing  this  art 
and  science  will  be  found  the  authors  of  the  present  volume.  All  of  tbem  are 
teachers  of  surgery  in  leading  medical  schools  and  hospitals  in  the  United  States 
and  Canada. 

Especial  prominence  has  been  given  to  Surgical  Bacteriology,  a  feature  which 
is  believed  to  be  unique  in  a  surgical  text-book  in  the  English  language.  Asep- 
sis and  Antisepsis  have  received  particular  attention.  The  text  is  brought  well 
up  to  date  in  such  important  branches  as  cerebral,  spinal,  intestinal,  and  pelvic 
surgery,  the  most  important  and  newest  operations  in  these  departments  being 
described  and  illustrated. 

The  text  of  the  entire  book  has  been  submitted  to  all  the  authors  for  their 
mutual  criticism  and  revision — an  idea  in  book-making  that  is  entirely  new  and 
original.  The  book  as  a  whole,  therefore,  expresses  on  all  the  important  sur- 
gical topics  of  the  day  the  consensus  of  opinion  of  the  eminent  surgeons  who 
have  joined  in  its  preparation. 

One  of  the  most  attractive  features  of  the  book  is  its  illustrations.  Very 
many  of  them  are  original  and  faithful  reproductions  of  photographs  taken 
directly  from  patients  or  from  specimens. 


CONTRIBUTORS : 


Dr.  Charles  H.  Burnett,  Philadelphia. 
Phineas  S.  Conner,  Cincinnati. 
Frederic  S.  Dennis,  New  York. 
William  W.  Keen,  Philadelphia. 
Charles  B.  Nancrede,  Ann  Arbor,  Mich. 
Roswell  Park,  BuflfaJo,  N.  Y. 
Lewis  S.  Pilcher,  New  York. 


Dr.  Nicholas  Senn,  Chicago. 

Francis  J.  Shepherd.  Montreal,  Canada. 

Lewis  A.  Stimson,  New  York. 

William  Thomson,  Philadelphia. 

J.  Collins  Warren,  Boston. 

J.  WiUiam  White,  Philadelphia. 


"If  this  text-book  is  a  fair  reflex  of  the  present  position  of  American  surgery,  we  must 
admit  it  is  of  a  very  high  order  of  merit,  and  that  English  surgeons  will  have  to  look  very 
carefully  to  their  laurels  if  they  are  to  preserve  a  position  in  the  van  of  surgical  Dractice."— 
London  Lancet. 


to  PV.   B.   SAUNDERS' 


^AN  AMERICAN  TEXT-BOOK  OF  GYNECOLOGY,  MEDICAL 
AND  SURGICAL,  for  the  use  of  Students   and   Practitioners. 

Edited  by  J.  M.  Baldy,  M.  D.  Forming  a  handsome  royal-octavo  volume 
of  718  pages,  with  341  illustrations  in  the  text  and  38  colored  and  half- 
tone plates.     Prices  :  Cloth,  ^6.00  net;  Sheep  or  Half-Morocco,  $7.00  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  all  anatomical  descriptions,  excepting  those  essential  to  a  cleat 
understanding  of  the  text,  have  been  omitted,  the  illustrations  being  largely  de- 
pended upon  to  elucidate  the  anatomy  of  the  parts.  This  vi^ork,  which  is 
thoroughly  practical  in  its  teachings,  is  intended,  as  its  title  implies,  to  be  a 
working  text-book  for  physicians  and  students.  A  clear  line  of  treatment  has 
been  laid  down  in  every  case,  and  although  no  attempt  has  been  made  to  dis- 
cuss mooted  points,  still  the  most  important  of  these  have  been  noted  and  ex- 
plained. The  operations  recommended  are  fully  illustrated,  so  that  the  reader, 
having  a  picture  of  the  procedure  described  in  the  text  under  his  eye,  cannot  fail 
to  grasp  the  idea.  All  extraneous  matter  and  discussions  have  been  carefully 
excluded,  the  attempt  being  made  to  allow  no  unnecessary  details  to  cumber 
the  text.  The  subject-matter  is  brought  up  to  date  at  every  point,  and  the 
work  is  as  nearly  as  possible  the  combined  opinions  of  the  ten  specialists  who 
figure  as  the  authors. 

In  the  revised  edition  much  new  material  has  been  added,  and  some  of  the 
old  eliminated  or  modified.  More  than  forty  of  the  old  illustrations  have  been 
replaced  by  new  ones,  which  add  very  materially  to  the  elucidation  of  the 
text,  as  they  picture  methods,  not  specimens.  The  chapters  on  technique  and 
after-treatment  have  been  considerably  enlarged,  and  the  portions  devoted  to 
plastic  work  have  been  so  greatly  improved  as  to  be  practically  new.  Hyste- 
rectomy has  been  rewritten,  and  all  the  descriptions  of  operative  procedures 
have  been  carefully  revised   and   fully  illustrated. 


CONTRIBUTORS : 


Dr.  Henry  T.  Byford. 
John  M.  Baldy. 
Edwin  Cragin. 
y.  H.  Etheridge. 
William  Goodell. 


Dr.  Howard  A.  Kelly. 
Florian  Krug. 
E.  E.  Montgomery. 
William  R.  Pryor. 
George  M.  Tuttle. 


"The  most  notable  contribution  to  gynecological  literature  since  1887,  ....  and  the  most 
complete  exponent  of  gynecology  which  we  have.  No  subject  seems  to  have  been  neglected, 
....  and  the  gynecologist  and  surgeon,  and  the  general  practitioner  who  has  any  desire 
to  practise  diseases  of  women,  will  find  it  of  practical  value.  In  the  matter  of  illustrations 
and  plates  the  book  surpasses  anything  we  have  seen." — Boston  Medical  and  Surgical 
Journal. 

"  A  thoroughly  modern  text-book,  and  gives  reliable  and  well-tempered  advice  and  in- 
struction."— Edinburgh  Medical  Journal. 

"  The  harmony  of  its  conclusions  and  the  homogeneity  of  its  style  give  it  an  individuality 
which  suggests  a  single  rather  than  a  multiple  authorship." — Annals  ^Surgery. 

"  It  must  command  attention  and  respect  as  a  worthy  representation  of  our  advanced 
clinical  teaching." — American  Journal  of  Medical  Sciences. 


CATALOGUE    OF  MEDICAL    WORKS. 


It 


*AN  AMERICAN  TEXT-BOOK  OF  THE  DISEASES  OF  CHIL- 
DREN.    By  American  Teachers.     Edited  by  Louis  Starr,  M.  D., 

assisted  by  Thompson  S.  Westcott,  M.  D.  In  one  handsome  royal-8vo 
volume  of  1250  pages,  profusely  illustrated  with  wood-cuts,  half-tone  and 
colored  plates.    Net  Prices:  Cloth,  $7.00;  Sheep  or  Half-Morocco,  $8.00. 

SECOND  EDITION,  REVISED  AND  ENLARGED. 

The  plan  of  this  work  embraces  a  series  of  original  articles  written  by  some 
sixty  well-known  paediatrists,  representing  collectively  the  teachings  of  the  most 
prominent  medical  schools  and  colleges  of  America.  The  work  is  intended  to 
be  a  PRACTICAL  book,  suitable  for  constant  and  handy  reference  by  the  practi- 
tioner and  the  advanced  student. 

Especial  attention  has  been  given  to  the  latest  accepted  teachings  upon  the 
etiology,  symptoms,  pathology,  diagnosis,  and  treatment  of  the  disorders  of  chil- 
dren, with  the  introduction  of  many  special  formulae  and  therapeutic  procedures. 

In  this  new  edition  the  whole  subject  matter  has  been  carefully  revised,  new 
articles  added,  some  original  papers  emended,  and  a  number  entirely  rewritten. 
The  new  articles  include  "  Modified  Milk  and  Percentage  Milk-Mixtures," 
"  Lithemia,"  and  a  section  on  "  Orthopedics."  Those  rewritten  are  "  Typhoid 
Fever,"  "Rubella,"  "Chicken-pox,"  "Tuberculous  Meningitis,"  "Hydroceph- 
alus," and  "Scurvy;"  while  extensive  revision  has  been  made  in  "Infant 
Feeding,"  "  Measles,"  "  Diphtheria,"  and  "  Cretinism."  The  volume  has  thus 
been  much  increased  in  size  by  the  introduction  of  fresh  material. 


COJf  TRIBUTORiS : 


Dr 


S.  S.  Adams,  Washington. 
John  Ashhurst,  Jr.,  Philadelphia. 
A.  D.  Blackader,  Montreal,  Canada. 
David  Bovaird,  New  York. 
Dillon  Brown,  New  York. 
Edward  M.  Buckingham,  Boston. 
Charles  W.  Burr,  Philadelphia. 
W.  E.  Casselberry,  Chicago. 
Henry  Dwight  Chapin,  New  York. 
W.  S.  Christopher,  Chicago. 
Archibald  Church,  Chicago. 
Floyd  M.  Crandall,  New  York. 
Andrew  F.  Currier,  New  York. 
Roland  G.  Curtin,  Philadelphia 
J.  M.  DaCosfa,  Philadelphia. 
I.  N.  Danforth,  Chicago. 
Edward  P.  Davis,  Philadelphia. 
John  B.  Deaver,  Philadelphia. 
G.  E.  de  Schwcinitz,  Philadelphia. 
John  Doming,  New  York. 
Charles  Warrington  Earle,  Chicago. 
Wm.  A.  Edwards,  San  Diego,  Cal. 
F.  Forchheimer,  Cincinnati. 
J.  Henry  Fruitnight,  New  York. 
J.  P.  Crozer  Griffith,  Philadelphia. 
W.  A.  Hardaway.  St.  Louis. 
M.  P    Hatfield,  Chicago. 
Barton  Cooke  Hirst,  Philadelphia. 
H.  Illoway,  Cincinnati. 
Henry  Jackson,  Boston. 
Charles  G.  Jennings,  Detroit. 
Henry  Koplik.  New  York. 


Dr.  Thomas  S.  Latimer,  Baltimore. 

Albert  R.  Leeds,  Hoboken,  N.  J. 

J.  Hendrie  Lloyd,  Philadelphia. 

George  Roe  Lockwood,  New  York. 

Henry  M.  Lyman,  Chicago. 

Francis  T.  Miles,  Baltimore. 

Charles  K    Mills,  Philadelphia. 

James  E-  Moore,  Minneapolis. 

F.  Gordon  Morrill,  Boston. 

John  H.  Musser,  Philadelphia. 

Thomas  R.  Neilson,  Philadelphia. 

W.  P.  Northrup,  New  York. 

William  Osier,  Baltimore. 

Frederick  A.  Packard,  Philadelphia. 

William  Pepper,  Philadelphia. 

Frederick  Peterson,  New  York. 

W.  T.  Plant,  Syracuse,  New  York. 

William  M.  Powell.  Atlantic  City. 

B.  K.  Rachford,  Cincinnati. 

B.  Alexander  Randall,  Philadelphia. 

Edward  O.  Shakespeare,  Philadelphia 

F.  C.  Shattuck,  Boston. 

J.  Lewis  Smith,  New  York. 

Louis  Starr,  Philadelphia. 

M.  Allen  Starr,  New  York. 

Charles  W.  Townsend,  Boston. 

James  Tyson,  Philadelphia. 

W.  S.  Thayer,  Baltimore. 

Victor  C.  Vaughan,  Ann  Arbor,  Mich 

Thompson  S.  Westcott,  Philadelphia. 

Henry  R.  Wharton,  Philadelphia. 

J.  William  White,  Philadelphia. 

J.  C.  Wilson,  Philadelphia. 


12 


IV.    B.    SAUNDERS' 


*AN  AMERICAN  TEXT-.BOOK  OF  GENITO-URINARY  AND 
SKIN  DISEASES.  By  47  Eminent  Specialists  and  Teachers.  Edited 
by  L.  Bolton  Bangs,  M.  D.,  Late  Professor  of  Genito-Urinary  and 
Venereal  Diseases,  New  York  Post-Giaduate  Medical  School  and  Hospital; 
and  W.  A.  Hardaway,  M.  D.,  Professor  of  Diseases  of  the  Skin,  Mis- 
souri Medical  College.  Imperial  octavo  volume  of  1229  pages,  u^ith  300 
engravings  and  20  full-page  colored  plates.  Cloth,  ^7.00  net;  Sheep  or 
Half- Morocco,  |8.oo  net. 

This  addition  to  the  series  of  "  American  Text-Books,"  it  is  confidently  be- 
lieved, will  meet  the  requirements  of  both  students  and  practitioners,  giving,  as 
it  does,  a  comprehensive  and  detailed  presentation  of  the  Diseases  of  the 
Genito-Urinary  Organs,  of  the  Venereal  Diseases,  and  of  the  Affections  of  the 
Skin. 

Having  secured  the  collaboration  of  well-known  authorities  in  the  branches 
represented  in  the  undertaking,  the  editors  have  not  restricted  the  contributors 
ii-  regard  to  the  particular  views  set  forth,  but  have  offered  every  facility  for  the 
free  expression  of  their  individual  opinions.  The  work  will  therefore  be  found 
to  be  original,  yet  homogeneous  and  fully  representative  of  the  several  depart- 
ments of  medical  science  with  which  it  is  concerned. 


CO^TTRIBUTORS : 


Dr.  Chas.  W.  Allen,  New  York. 
I.  E.  Atkinson,  Baltimore. 
L   Bolton  Bangs,  New  York. 
P.  R.  Bolton,  New  York. 
Lewis  C.  Bosher,  Richmond,  Va. 
John  T.  Bowen,  Boston. 
J.  Abbott  Cantrell.  Philadelphia. 
William  T.  Corlett,  Cleveland,  Ohio. 
B.  Farquhar  Curtis,  New  York. 
Condict  W.  Cutler,  New  York. 
Isadore  Dyer,  New  Orleans. 
Christian   Fenger,  Chicago. 
John  A.  Fordyce,  New  York. 
Eugene  Fuller,  New  York. 
R.  H.  Greene,  New  York. 
Joseph  Grindon,  St.  Louis. 
Graeme  M.  Hammond,  New  York. 
W.  A.  Hardaway,  St.  Louis. 
M.  B.  Hartzell,  Philadelphia. 
Louis  Heitzmann.  New  York. 
James  S.  Howe,  Boston. 
George  T.  Jackson,  New  York. 
Abraham  Jacobi,  New  York. 
James  C.  Johnston,  New  York. 


Dr.  Hermann  G.  Klotz,  New  York. 
J.  H.  Linsley,  Burlington,  Vt. 
G.  F.  Lydston,  Chicago. 
Hartwell  N.  Lyon,  St.  Louis. 
Edward  Martin,  Philadelphia. 
D.  G.  Montgomery,  San  Francisco. 
James  Pedersen,  New  York. 
S.  Pollitzer,  New  York. 
Thomas  R.  Pooley,  New  York. 
A.  R.  Robinson,  New  York. 
A.  E.  Regensburger,  San  Francisco. 
•  Francis  J.  Shepherd,  Montreal,  Can. 
S.  C.  Stanton,  Chicago,  111. 
Emmanuel  J.  Stout,  Philadelphia. 
Alonzo'E.  Taylor    Philadelphia. 
Robert  W.  Taylor,  New  York. 
Paul  Thorndike,  Boston. 
H.  Tuholske,  St.  Louis. 
Arthur  Van  Harlingen,  Philadelphia. 
Francis  S.  Watson,  Boston. 
J.  William  White,  Philadelphia. 
J.  McF.  Winfield,  Brooklyn. 
Alfred  C.  Wood,  Philadelphia. 


"This  voluminous  work  is  thoroughly  up  to  date,  and  the  chapters  on  genito-urinary  dis- 
eases are  especially  valuable.  The  illustrations  are  fine  and  are  mostly  original.  Ihe  section 
on  dermatolog^j'  is  concise  and  in  every  way  admirable."— y<?«r«<2/  of  the  American  Medical 
Association. 

"This  volume  is  one  of  the  best  yet  issued  of  the  publisher's  series  of  'American  Text- 
Books.'  The  list  of  contributors  represents  an  extraordinary  array  of  talent  and  extended 
experience.  The  book  will  easily  take  the  place  in  comprehensiveness  and  value  of  the 
half  dozen  or  more  costly  works  on  these  subjects  which  have  hitherto  been  necessary  to  a 
well-equipped  library." — New  York  Polyclinic. 


CATALOGUE    OF  MEDICAL    WORKS. 


13 


*  AN  AMERICAN  TEXT-BOOK  OF  DISEASES  OF  THE  EYE, 
EAR,  NOSE,  AND  THROAT.    Edited  by  George  E.  de  Schweinitz, 

A.  M.,  M.  D.,  Professor  of  Ophthalmology,  Jefferson  Medical  College;  and 

B.  Alexander  Randall,  A.  M.,  M.  D.,  Clinical  Professor  of  Diseases  of 
the  Ear,  University  of  Pennsylvania.  One  handsome  imperial  octavo 
volume  of  1251  pages;  766  illustrations,  59  of  them  colored.  Prices: 
Cloth,  ^7.00  net;  Sheep  or  Half- Morocco,  $8.00  net. 

Just  Issued, 

The  present  work  is  the  only  book  ever  published  embracing  diseases  of  the 
intimately  related  organs  of  the  eye,  ear,  nose,  and  throat.  Its  special  claim 
to  favor  is  based  on  encyclopedic,  authoritative,  and  practical  treatment  of  the 
subjects. 

Each  section  of  the  book  has  been  entrusted  to  an  author  who  is  specially 
identified  with  the  subject  on  which  he  writes,  and  who  therefore  presents  his 
case  in  the  manner  of  an  expert.  Uniformity  is  secured  and  overlapping  pre- 
vented by  careful  editing  and  by  a  system  of  cross-references  which  forms  a 
special  feature  of  the  volume,  enabling  the  reader  to  come  into  touch  with  all 
that  is  said  on  any  subject  in  different  portions  of  the  book. 

Particular  emphasis  is  laid  on  the  most  approved  methods  of  treatment,  so 
that  the  book  shall  be  one  to  which  the  student  and  practitioner  can  refer  for 
information  in  practical  work.  Anatomical  and  physiological  problems,  also, 
are  fully  discussed  for  the  benefit  of  those  who  desire  to  investigate  the  more 
abstruse  problems  of  the  subject. 


CONTRIBUTORS ; 


Dr.  Henry  A.  Alderton,  Brooklyn. 
Harrison  Allen,  Philadelphia. 
Frank  All  port,  Chicago. 
Morris  J.  Asch.  New  York. 
S.  C.  Ayres,  Cincinnati. 
R.  O.  Beard,  Minneapolis. 
Clarence  J.  Blake,  Boston. 
Arthur  A.  Bliss,  Philadelphia. 
Albert  P.  Brubaker,  Philadelphia. 
J.  H.  Bryan,  Washington,  D.  C. 
Albert  H.  Buck,  New  York. 
F.  Boiler,  Montreal,  Can. 
Swan  M.  Burnett,  Washington,  D    C 
Flemming  Carrow,  Ann  Arbor,  Mich. 
W.  E.  Casselberry,  Chicago. 
C')lman  W.  Cutler,  New  York. 
Edward  B.  Dench,  New  York. 
William  S.  Dennett.  New  York. 
George  E.  de  Schweinitz,  Philadelphia. 
Alexander  Diiane,  New  York. 
John  W.  Farlow,  Boston,  Mass. 
Walter  J.  Freeman,  Philadelphia. 
HGifTord,  Omaha,  Neb. 
W.  C.  Glasgow,  St.  Louis. 
J    Orne  Cireen,  Boston. 
Ward  A.  Holden,  New  York. 
Christian  R.  Holmes,  Cincinnati. 
William  E.  Hopkins,  San  Francisco. 
F.  C.  Hotz,  Chiciigo. 
Lucien  Howe,  Jiijfialo,  N,  Y, 


Dr.  Alvin  A.  Hubbell,  Buffalo,  N.  Y. 
Edward  Jackson,  Philadelphia. 
J.  Ellis  Jennings,  St.  Louis. 
Herman  Knypp,  New  York. 
Chas.  W.  Kollock,  Charleston,  S.  C. 
G.  A.  Leland,  Boston. 
J.  A.  Lippincott,  Pittsburg,  Pa. 
G.  Hudson  Makuen,  Philadelphia. 
John  H.  McCollom,  Boston. 
H.  G.  Miller,  Providence,  R.  L 
B.  L.  MiUiken,  Cleveland,  Ohio. 
Robert  C.  Myles,  New  York. 
James  E.  Newcomb,  New  York. 
R.  J.  Phillips,  Philadelphia. 
George  A.  Piersol,  Philadelphia. 
W.  P.  Porcher,  Charleston,  S.  C. 
B.  Alex.  Randall,  Philadelphia. 
Robert  L.  Randolph,  Baltimore. 
John  O.  Roe,  Rochester,  N.  Y. 
Charles  E.  de  M.  Sajous,  Philadelphia. 
J.  E.  Sheppard.  Brooklyn,  N.  Y. 
E.  L.  Shurly,  Detroit,  Mich. 
William  M.  Sweet,  Philadelphia. 
Samuel  I'heobnld.  Baltimore,  Md. 
A.  G.  Thomson,  Philadelphia. 
Clarence  A.  Ve.iscy,  Philadelphia. 
John  E.  Weeks,  New  York. 
Casey  A.  Wood,  Chicago,  111. 
Jonathan  Wright,  Brooklyn. 
H.  V.  Wiirdemann,  Milwaukee,  Wis. 


14 


m   B.    SAUNDERS' 


*AN  AMERICAN  YEAR-BOOK  OF  MEDICINE  AND  SUR- 
GERY. A  Yearly  Digest  of  Scientific  Progress  and  Authoritative 
Opinion  in  all  branches  of  Medicine  and  Surgery,  drawn  from  journals, 
monographs,  and  text-books  of  the  leading  American  and  Foreign  authors 
and  investigators.  Collected  and  arranged,  with  critical  editorial  com- 
ments, by  eminent  American  specialists  and  teachers,  under  the  general 
editorial  charge  of  George  M.  Gould,  M.D.  One  handsome  imperial 
octavo  volume  of  about  1200  pages.  Uniform  in  style,  size,  and  general 
make-up  with  the  "American  Text-Book"  Series.  Clotli,  $6.50  net; 
Half-Morocco,  ^7.50  net. 

Now  Ready,  Volumes  for  1896,  1897,  1898,  1899, 

Notwithstanding  the  rapid  multiplication  of  medical  and  surgical  works,  still 
these  publications  fail  to  meet  fully  the  requirements  of  the  general  physician, 
inasmuch  as  he  feels  the  need  of  something  more  than  mere  text-books  of  well- 
known  principles  of  medical  science. 

This  deficiency  would  best  be  met  by  current  journalistic  literature,  but  most 
practitioners  have  scant  access  to  this  almost  unlimited  source  of  information, 
and  the  busy  practiser  has  but  little  time  to  search  out  in  periodicals  the  many 
interesting  cases  whose  study  would  doubtless  be  of  inestimable  value  in  his 
practice.  Therefore,  a  work  which  places  before  the  physician  in  convenient 
form  an  epitoitiization  of  this  literature  by  persons  competent  to  pronounce  upon 

The  Value  of  a  Discovery  or  of  a  Method  of  Treatment 

cannot  but  command  his  highest  appreciation.  It  is  this  critical  and  judicial 
function  that  is  assumed  by  the  Editorial  staff  of  the  "  American  Year-Book 
of  Medicine  and  Surgery." 


COUTTRIB UXORS  : 


Dr.  Samuel  W.  Abbott.  Boston. 
John  J.  Abel,  Baltimore. 
J.  M.  Baldy,  Philadelphia. 
Charles  H.  Burnett,  Philadelphia. 
Archibald  Church,  Chicago. 
J.  Chalmers  DaCosta,  Philadelphia. 
W.  A.  N.  Borland,  Philadelphia. 
Louis  A.  Duhring,  Philadelphia. 
D.  L.  Edsall,  Philadelphia. 
Virgil  P.  Gibney,  New  York. 
Henry  A.  Griffin,  New  York. 
John  Guiteras,  Philadelphia. 
C.  A.  Hamann,  Cleveland. 
Alfred  Hand,  Jr.,  Philadelphia. 


Dr.  Howard  E.  Hansell,  Philadelphia. 
M.  B.  Hartzell.  Philadelphia. 
Barton  Cooke  Hirst,  Philadelphia. 
E.  Fletcher  Ingals,  Chicago. 
Wyatt  Johnston,  Montreal. 
W.  W.  Keen,  Philadelphia. 
Henry  G.  Ohls,  Chicago. 
Wendell  Reber,  Philadelphia. 
David  Riesman,  Philadelphia. 
Louis  Starr,  Philadelphia. 
Alfred  Stengel,  Philadelphia. 
G.  N.  Stewart.  Cleveland. 
J.  R.  Tillinghast,  New  York. 
J.  Hilton  Waterman,  New  York. 


"  It  is  difficult  to  know  which  to  admire  most — the  research  and  industry  of  the  distin- 
guished band  of  experts  whom  Dr.  Gould  has  enlisted  in  the  service  of  the  Year-Book,  or  the 
wealth  and  abundance  of  the  contributions  to  every  department  of  science  that  have  been 
deemed  worthy  of  analysis.  ...  It  is  much  more  than  a  mere  compilation  of  abstracts,  for, 
as  each  section  is  entrusted  to  experienced  and  able  contributors,  the  reader  has  the  advan- 
tage of  certain  critical  commentaries  and  expositions  .  .  .  proceeding  from  writers  fully 
qualified  to  perform  these  tasks.  ...  It  is  emphatically  a  book  which  should  find  a  place  in 
every  medical  library,  and  is  in  several  respects  niore  useful  t^^an  the  famous  '  Jahrbiicl;ier' 
oiGerT!\a.ny,"'^Z^pndpnIfancet. 


CATALOGUE    OF  MEDICAL    WORKS.  1 5 

*  ANOMALIES  AND  CURIOSITIES  OF  MEDICINE.  By  George 
M.  Gould,  M.D.,  and  Walter  L.  Pyle,  M.D.  An  encyclopedic  collec- 
tion of  rai-e  and  extraordinary  cases  and  of  the  most  striking  instances  of 
abnormality  in  all  branches  of  Medicine  and  Surgery,  derived  from  an  ex- 
haustive research  of  medical  literature  from  its  origin  to  the  present  day, 
abstracted,  classified,  annotated,  and  indexed.  Handsome  imperial  octavo 
volume  of  968  pages,  with  295  engravings  in  the  text,  and  12  full-page 
plates.     Cloth,  ^6.00  net ;   Half-Morocco,  ^^7.00  net. 

Several  years  of  exhaustive  research  have  been  spent  by  the  authors  in  the 
great  medical  libraries  of  the  United  States  and  Europe  in  collecting  the  mate- 
rial for  this  work.  Medical  literature  of  all  ages  and  all  languages  has 
been  carefully  searched,  as  a  glance  at  the  Bibliographic  Index  will  show.  The 
facts,  which  will  be  of  extreme  value  to  the  author  and  lecturer,  have  been 
arranged  and  annotated,  and  full  reference  footnotes  given,  indicating  whence 
they  have  been  obtained. 

In  view  of  the  persistent  and  dominant  interest  in  the  anomalous  and  curious, 
a  thorough  and  systematic  collection  of  this  kind  (the  first  of  which  the 
authors  have  knowledge)  must  have  its  own  peculiar  sphere  of  usefulness. 

As  a  complete  and  authoritative  Book  of  Reference  it  will  be  of  value  not 
only  to  members  of  the  medical  profession,  but  to  all  persons  interested  in  gen- 
eral scientific,  sociologic,  and  medico-legal  topics ;  in  fact,  the  general  interest 
of  the  subject  and  the  dearth  of  any  complete  work  upon  it  make  this  volume 
one  of  the  most  important  literary  innovations  of  the  day. 

"One  of  the  most  valuable  contributions  ever  made  to  medical  literature.  It  is,  so  far  as 
we  know,  absolutely  unique,  and  every  page  is  as  fascinating  as  a  novel.  Not  alone  for  the 
medical  profession  has  this  volume  value  :  it  will  serve  as  a  book  of  reference  for  all  who  are 
interested  in  general  scientific,  sociologic,  or  medico-legal  topics." — Brooklyn  Medical  your- 
nal. 

NERVOUS  AND  MENTAL  DISEASES.  By  Archibald  Church, 
M.  D.,  Professor  of  Clinical  Neurology,  Mental  Diseases,  and  Medical 
Jurisprudence,  Northwestern  University  Medical  School;  and  Frederick 
Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases,  Woman's  Medi- 
cal College,  New  York.  Handsome  octavo  volume  of  843  pages,  with 
over  300  illustrations.  Prices:  Cloth,  $5.00  net;  Half-Morocco,  36.00 
net. 

Just  Issued, 

This  book  is  intended  to  furnish  students  and  practitioners  with  a  practical, 
working  knowledge  of  nervous  and  mental  diseases.  Written  by  men  of  wide 
experience  and  authority,  itwill  present  the  many  re  cent  additions  to  the  subject. 
The  book  is  nrit  filled  with  an  extended  dissertation  on  anatomy  and  pathology, 
Ijut,  treating  these  points  in  connection  with  special  conditions,  it  lays  particular 
stress  on  methods  of  examination,  diagnosis,  and  treatment.  In  this  respect  the 
work  will  be  unusually  complete  and  valuable,  laying  down  the  definite  courses 
of  procedure  which  the  authors  have  found  to  be  most  generally  satisfactory. 


1 6  W.   B.    SAUNDERS' 


A  TEXT-BOOK  OF  PATHOLOGY.  By  Alfred  Stengel,  M.  D., 
Instructor  in  Clinical  Medicine  in  the  University  of  Pennsylvania;  Clinical 
Professor  of  Medicine  in  the  Woman's  Medical  College  of  Pennsylvania; 
Physician  to  the  Philadelphia  Hospital ;  Physician  to  the  Children's  Hos- 
pital, Philadelphia.  Handsome  octavo  volume  of  848  pages,  v^^ith  362 
illustrations,  many  of  which  are  in  colors.  Prices :  Cloth,  ^4.00  net ; 
Half-Morocco,  $5.00  net. 

Just  Issued, 

In  this  work  the  practical  application  of  pathological  facts  to  clinical  medicine 
is  considered  more  fully  than  is  customary  in  works  on  pathology.  "While  the 
subject  of  pathology  is  treated  in  the  broadest  way  consistent  with  the  size  of 
the  book,  an  effort  has  been  made  to  present  the  subject  from  the  point  of  view 
of  the  clinician.  The  general  relations  of  bacteriology  to  pathology  are  dis- 
cussed at  considerable  length,  as  the  importance  of  these  branches  deserves.  It 
will  be  found  that  the  recent  knowledge  is  fully  considered,  as  well  as  older  and 
more  widely-known  facts. 

In  the  second  part  of  the  work  the  pathology  of  individual  organs  and  tissues 
is  treated  systematically  and  quite  fully  under  subheadings  that  clearly  indicate 
the  subject-matter  of  each  page. 

The.  particular  points  of  the  book  to  be  emphasized  are  the  clear,  concise 
language,  the  convenient  arrangement  of  matter,  the  practical  teaching  value 
of  the  large  collection  of  illustrations,  and  the  modern  and  judicious  treatment 
of  the  entire  subject. 

A  TEXT-BOOK  OF  OBSTETRICS.  By  Barton  Cooke  Hirst,  M.Dr, 
Professor  of  Obstetrics  in  the  University  of  Pennsylvania.  Handsome  oc- 
tavo volume  of  846  pages,  with  618  illustrations  and  seven  colored  plates. 
Prices :  Cloth,  I5.00  net ;   Half-Morocco,  ^6.00  net. 

Just  Issued, 

This  work,  which  has  been  in  course  of  preparation  for  several  years,  is  in- 
tended as  an  ideal  text-book  for  the  student  no  less  than  an  advanced  treatise 
for  the  obstetrician  and  for  general  practitioners.  It  represents  the  very  latest 
teaching  in  the  practice  of  obstetrics  by  a  man  of  extended  experience  and 
recognized  authority.  The  book  emphasizes  especially,  as  a  work  on  obstetrics 
should,  the  practical  side  of  the  subject,  and  to  this  end  presents  an  unusually 
large  collection  of  illustrations.  A  great  number  of  these  are  new  and  original, 
and  the  whole  collection  will  form  a  complete  atlas  of  obstetrical  practice. 
An  extremely  valuable  feature  of  the  book  is  the  large  number  of  refer- 
ences to  cases,  authorities,  sources,  etc.,  forming,  as  it  does,  a  valuable  bib- 
liography of  the  most  recent  and  authoritative  literature  on  the  subject 
of  obstetrics.  As  already  stated,  this  work  records  the  wide  practical  ex- 
perience of  the  author,  which  fact,  combined  with  the  brilliant  presentation 
of  the  subject,  will  doubtless  render  this  one  of  the  most  notable  books  orj 
obstetrics  that  has  yet  appeared, 


CATALOGUE    OF  MEDICAL    WORKS.  1 7 

A    TEXT-BOOK    OF    THE    PRACTICE    OF    MEDICINE.      By 

James  M.  Anders,  M.D.,  Ph.D.,  LL.D.,  ProfL-ssor  of  the  Practice  of 
Medicine  and  of  Clinical  Medicine,  Medico-Chirurgical  College,  Piiiladel- 
phia.  In  one  handsome  octavo  volume  of  1287  pages,  fully  illustrated. 
Cloth,  ^5.50  net;  Sheep  or  Half-Morocco,  ^6.50  net. 

Second  Edition.     First  Edition  Exhausted  in 
Five  Mont  lis. 

This  work  gives  in  a  comprehensive  manner  the  results  of  the  latest  scientific 
studies  bearing  upon  medical  affections,  and  portrays  with  rare  force  and  clear- 
ness the  clinical  pictures  of  the  different  diseases  considered.  The  practical 
points,  particularly  with  reference  to  diagnosis  and  treatment,  are  completely 
stated  and  are  presented  in  a  most  convenient  form ;  for  example,  the  differ- 
ential diagnosis  has  in  many  instances  been  tabulated,  no  less  than  fifty-six 
diagnostic  tables  being  given. 

The  first  edition  of  this  work  having  been  exhausted  in  so  short  a  time,  the 
author  has  not  found  it  necessary  to  make  an  extensive  revision,  but  has  simply 
availed  himself  of  the  opportunity  to  make  a  few  changes  of  minor  importance. 

"  It  is  an  excellent  book — concise,  comprehensive,  thorough,  and  up  to  date.  It  is  a 
credit  to  you;  but,  more  than  that,  it  is  a  credit  to  the  profession  of  Philadelphia -to  us." 
— James  C.  Wilson,  Professor  of  the  Practice  of  Medicine  and  Clinical  Medicine,  Jeffer- 
son Medical  College,  Philadelphia. 

"I  consider  Dr.  Anders'  book  not  only  the  best  late  work  on  Medical  Practice, but  by  far 
the  best  that  has  ever  been  published.  It  is  concise,  systematic,  thorough,  and  fully  up  to 
date  in  everything.  I  consider  it  a  great  credit  to  both  the  author  and  the  publisher." — A. 
C.  CowPERTHWAiTE,  President  of  the  Illinois  Homeopathic  Medical  Association. 

DISEASES  OF  THE  STOMACH.  By  William  W.  Van  Valzaii, 
M.  D.,  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  System 
and  the  Blood,  New  York  Polyclinic;  and  J  Douglas  Nisbet,  M.  D., 
Adjunct  Professor  of  General  Medicine  and  Diseases  of  the  Digestive  Sys- 
tem and  the  Blood,  New  York  Polyclinic.  Octavo  volume  of  674  pages, 
illustrated.     Cloth,  ^3.50  net. 

An  eminently  practical  book,  intended  as  a  guide  to  the  student,  an  aid  to  the 
physician,  and  a  contribution  to  scientific  medicine.  It  aims  to  give  a  complete 
description  of  the  modern  methods  of  diagnosis  and  treatment  of  diseases  of  the 
stomach,  and  to  reconstruct  the  pathology  of  the  stomach  in  keeping  with  the 
revelations  of  scientific  researcli.  The  book  is  clear,  practical,  and  complete, 
and  contains  the  results  of  the  authors'  investigations  and  of  their  extensive  ex- 
perience as  specialists.  Particular  attention  is  given  to  the  important  subject  of 
dietetic  treatment.  The  diet-lists  are  very  complete,  and  are  so  arranged  that 
selections  can  readily  be  made  to  suit  individual  cases. 

"This  is  the  most  satisfactory  work  on  the  subject  in  the  English  language." — Chicago 
Medical  Recorder. 

"The  article  on  diet  and  general  medication  is  one  of  the  most  valuable  in  the  book,  and 
should  be  read  by  every  practising  physician." — New  York  Medical  fournal. 


1 8  IV.   B.    SAUNDERS' 


SURGICAL  DIAGNOSIS    AND    TREATMENT.     By   J.  W.    Mac- 
DONALD,  M.  D.,  Edin.,  F.  R.  C.  S.,  Edin.,  Professor  of  the  Practice  of  Sur- 
gery and  of  Clinical  Surgery  in  Hamline  University ;  Visiting  Surgeon  to  St. 
Barnabas'   Hospital,  Minneapolis,  etc.     Handsome  octavo  volume  of  8oo 
pages,  profusely  illustrated.     Cloth,  $5.00  net;  Half-Morocco,  ^6.00  net. 
This  work  aims  in  a  comprehensive  manner  to  furnish  a  guide  in  matters  of 
surgical  diagnosis.     It  sets  forth  in  a  systematic  way  the  necessities  of  examina- 
tions and  tiie  proper  methods  of  making  them.     The  various  portions  of  the 
body  are  then  taken  up  in  order  and  the  diseases  and  injuries  thereof  succinctly 
considered  and  the  treatment  briefly  indicated.     Practically  all  the  modern  and 
approved  operations  are  described  with  thoroughness  and  clearness.     The  work 
concludes  with  a  chapter  on  the  use  of  the  Rontgen  rays  in  surgery, 

"The  work  is  brimful  of  just  the  kind  of  practical  information  that  is  useful  alike  to 
students  and  practitioners.  It  is  a  pleasure  to  commend  the  book  because  of  its  intrinsic 
value  to  the  medical  practitioner." — Cincinnati  Lancet- Clinic. 

PATHOLOGICAL  TECHNIQUE.  A  Practical  Manual  for  Laboratory 
Work  in  Pathology,  Bacteriology,  and  Morbid  Anatomy,  with  chapters  on 
Post-Mortem  Technique  and  the  Performance  of  Autopsies,  By  Frank 
B.  Mallory,  a,  M.,  M.  D.,  Assistant  Professor  of  Pathology,  Harvard 
University  Medical  School,  Boston;  and  James  H,  Wright,  A,  M.,  M.  D,, 
Instructor  in  Pathology,  Harvard  University  Medical  School,  Boston.  Oc- 
tavo volume  of  396  pages,  handsomely  illustrated.     Cloth,  ^2.50  net. 

This  book  is  designed  especially  for  practical  use  in  pathological  laboratories, 
both  as  a  guide  to  beginners  and  as  a  source  of  reference  for  the  advanced.  The 
book  will  also  meet  the  wants  of  practitioners  who  have  opportunity  to  do  general 
pathological  work.  Besides  the  methods  of  post-mortem  examinations  and  of 
bacteriological  and  histological  investigations  connected  with  autopsies,  the 
special  methods  employed  in  clinical  bacteriology  and  pathology  have  been 
fully  discussed. 

"  One  of  the  most  complete  works  on  the  subject,  and  one  which  should  be  in  the  library 
of  every  physician  who  hopes  to  keep  pace  with  the  great  advances  made  in  pathology." — 
Journal  of  American  Medical  Association. 

THE  SURGICAL  COMPLICATIONS  AND  SEQUELS  OF  TY- 
PHOID FEVER.  By  Wm.  W,  Keen,  M.  D.,  LL.D,,  Professor  of  the 
Principles  of  Surgery  and  of  Clinical  Surgery,  Jefferson  Medical  College, 
Philadelphia,     Octavo  volume  of  386  pages,  illustrated.     Cloth,  ^3.00  net. 

This  monograph  is  the  only  one  in  any  language  covering  the  entire  subject 
of  the  Surgical  Complications  and  Sequels  of  Typhoid  Fever.  The  work  will 
prove  to  be  of  importance  and  interest  not  only  to  the  general  surgeon  and  phy- 
sician, but  also  to  many  specialists — laryngologists,  ophthalmologists,  gynecolo- 
gists, pathologists,  and  bacteriologists — as  the  subject  has  an  important  bearing 
upon  each  one  of  their  spheres.  The  author's  conclusions  are  based  on  reports 
of  over  1700  cases,  including  practically  all  those  recorded  in  the  last  fifty  years. 
Reports  of  cases  have  been  Ijrought  down  to  date,  many  having  been  added 
while  the  work  was  in  press. 

"  This  is  probably  the  first  and  only  work  in  the  English  language  that  gives  the  reader  a 
clear  view  of  what  typhoid  fever  really  is,  and  what  it  does  and  can  do  to  the  human  organ- 
ism. This  book  should  be  in  the  possession  of  every  medical  man  in  America," — American 
Medico-Surgical  Bulletin. 


CATALOGUE    OF  MEDICAL    WORKS.  1 9 

MODERN  SURGERY,  GENERAL  AND  OPERATIVE.  By  John 
Chalmers  DaCosta,  M.D.,  Clinical  Professor  of  Surgery,  Jefferson  Medi- 
cal College,  Philadelphia;  Surgeon  to  the  Philadelphia  Hospital,  etc. 
Handsome  octavo  volume  of  911  pages,  profusely  illustrated.  Cloth,  $4.00 
net;   Half- Morocco,  ^5.00  net. 

Second  Edition,  Retvritteu  and  Greatly  Enlarged. 

The  remarkable  success  attending  DaCosta's  Manual  of  Surgery,  and  the 
general  favor  v^ith  which  it  has  been  received,  have  led  the  author  in  this 
revision  to  produce  a  complete  treatise  on  modern  surgery  along  the  same  lines 
that  made  the  former  edition  so  successful.  The  book  has  been  entirely  re- 
vv^ritten  and  very  much  enlarged.  The  old  edition  has  long  been  a  favorite  not 
only  with  students  and  teachers,  but  also  with  practising  physicians  and  sur- 
geons, and  it  is  believed  that  the  present  work  will  find  an  even  wider  field  of 
usefulness. 

"We  know  of  no  small  work  on  surgery  in  the  English  language  which  so  well  fulfils  the 
requirements  of  the  modern  student." — Medico-Chirurgical  Journal,  Bristol,  England. 

"  The  author  has  presented  concisely  and  accurately  the  principles  of  modern  surgery. 
The  book  is  a  valuable  one  which  can  be  recommended  to  students  and  is  of  great  value  to 
the  general  practitioner." — American  Journal  of  the  Medical  Sciences. 

A  MANUAL  OF  ORTHOPEDIC  SURGERY.  By  James  E.  Moore, 
M.D.,  Professor  of  Orthopedics  and  Adjunct  Professor  of  CHnical  Surgery, 
University  of  Minnesota,  College  of  Medicine  and  Surgery.  Octavo  volume 
of  356  pages,  with  177  beautiful  illustrations  from  photographs  made  spec- 
ially for  this  work.     Cloth,  ^2.50  net. 

A  practical  book  based  upon  the  author's  experience,  in  which  special  stress 
is  laid  upon  early  diagnosis  and  treatment  such  as  can  be  carried  out  by  the 
general  practitioner.  The  teachings  of  the  author  are  in  accordance  with  his 
belief  that  true  conservatism  is  to  be  found  in  the  middle  course  between  the 
surgeon  who  operates  too  frequently  and  the  orthopedist  who  seldom  operates, 

"A  very  demonstrative  work,  every  illustration  of  which  conveys  a  lesson.  The  work  is 
a  most  excellent  and  commendable  one,  which  we  can  certainly  endorse  with  pleasure." — 
St.  Louis  Medical  attd  Surgical  yournal. 

ELEMENTARY   BANDAGING    AND    SURGICAL    DRESSING. 

With  Directions  concerning  the  Immediate  Treatment  of  Cases  of  Emer- 
gency. For  the  use  of  Dressers  and  Nurses.  By  Walter  Pye,  F.R.C.S., 
late  Surgeon  to  St.  Mary's  Hospital,  London.  Small  i2mo,  with  over  80 
illustrations.     Cloth,  flexible  covers,  75  cents  net. 

This  little  book  is  chiefly  a  condensation  of  those  portions  of  Pye's  "  Surgical 
Handicraft"  which  deal  with  bandaging,  splinting,  etc.,  and  of  those  which 
treat  of  the  management  in  the  first  instance  of  cases  of  emergency.  The 
directions  given  are  thoroughly  practical,  and  the  book  will  prove  extremely  use- 
ful to  students,  surgical  nurses,  and  dressers. 

"  The  author  writes  well,  the  diagrams  are  clear,  and  the  book  itself  is  small  and  portable, 
although  the  paper  and  type  are  good." — British  Medical  yournal. 


20  IV.   B.   SAUNDERS' 


A    TEXT-BOOK    OF    MATERIA    MEDICA,    THERAPEUTICS 
AND  PHARMACOLOGY.     By  George  F.  Butler,  Ph.G.,  M.D., 
Professor  of  Materia  Medica  and  of  Clinical  Medicine  in  the  College  of 
Physicians   and    Surgeons,   Chicago;    Professor  of    Materia    Medica   and 
Therapeutics,    Northwestern    University,  Woman's    Medical    School,   etc. 
Octavo,  860  pages,  illustrated.     Cloth,  ^4.00  net ;  Sheep,  ^5.00  net. 
Second  Edition,  Thoroughly  Revised, 
A  clear,  concise,  and  practical  text-book,  adapted  for  permanent  reference  no 
less  than  for  the  requirements  of  the  class-room. 

The  recent  important  additions  made  to  our  knowledge  of  the  physiological 
action  of  drugs  are  fully  discussed  in  the  present  edition.  Many  alterations  also 
have  been  made  in  the  chapters  on  Diuretic's  and  Cathartics. 

"  Taken  as  a  whole,  the  book  may  fairly  be  considered  as  one  of  the  most  satisfactory  of  any 
single-volume  works  on  materia  medica  in  the  n\2irke.t."— Journal  of  the  American  JMedical 
Association. 

TUBERCULOSIS     OF     THE     GENITO-URINARY     ORGANS, 

MALE  AND  FEMALE.     By  Nicholas  Senn,  M.D.,  Ph.D.,  LL.D., 

Professor  of  the  Practice  of  Surgery  and  of  Clinical  Surgery,  Rush  Medical 

College,   Chicago.     Handsome   octavo  volume   of  320  pages,   illustrated^ 

Cloth,  ^3.00  net. 

Tuberculosis  of  the  male  and  female  genito-urinary  organs  is  such  a  frequent, 
distressing,  and  fatal  affection  that  a  special  treatise  on  the  subject  appears  to 
fill  a  gap  in  medical  literature.  In  the  present  work  the  bacteriology  of  the  sub- 
ject has  received  due  attention,  the  modern  resources  employed  in  ihe  differen- 
tial diagnosis  between  tubercular  and  other  inflammatory  affections  are  fully 
described,  and  the  medical  and  surgical  therapeutics  are  discussed  in  detail. 

"An  important  book  upon  an  important  subject,  and  written  by  a  man  of  mature  judg- 
ment and  wide  experience.  The  author  has  given  us  an  instructive  book  upon  one  of  the 
most  important  subjects  of  the  day." — Clinical  Reporter. 

"A  work  which  adds  another  to  the  many  obligations  the  profession  owes  the  talented 
author." — Chicago  Medical  Recorder. 

A  TEXT-BOOK  OF  DISEASES  OF  WOMEN.  By  Charles  B. 
Penrose,  M.D.,  Ph.D.,  Professor  of  Gynecology  in  the  University  of 
Pennsylvania;  Surgeon  to  the  Gynecean  Hospital,  Philadelphia.  Octavo 
volume  of  529  pages,  with  217  illustrations,  nearly  all  from  drawings  made 
for  this  work.     Cloth,  ^3.50  net. 

Second  Edition,  JRevised. 
In  this  work,  which  has  been  written  for  both  the  student  of  gynecology  and 
the  general  practitioner,  the  author  presents  the  best  teaching  of  modern  gyne- 
cology untrammelled  by  antiquated  theories  or  methods  of  treatment.  In  most 
instances  but  one  plan  of  treatment  is  recommended,  to  avoid  confusing  the 
student  or  the  physician  M^ho  consults  the  book  for  practical  guidance. 

"  I  shall  value  very  highly  the  copy  of  Penrose's  '  Diseases  of  Women '  received.  I  have 
already  recommended  it  to  my  class  as  THE  BEST  book." — Howard  A.  Kelly,  Professor 
of  Gynecology  and  Obstetrics,  Johns  Hopkins  University,  Baltimore,  Md. 

"  The  book  is  to  be  commended  without  reserve,  not  only  to  the  student  but  to  the  general 
practitioner  who  wishes  to  have  the  latest  and  best  modes  of  treatment  explained  with  absolute 
clearness." — Therapeutic  Gazette. 


CATALOGUE    OF  MEDICAL    WORKS.  21 


SURGICAL  PATHOLOGY  AND  THERAPEUTICS.  By  John 
Collins  Warren,  M.  D.,  LL.D.,  Professor  of  Surgery,  Medical  Depart- 
ment Harvai-d  University ;  Surgeon  to  the  Massachusetts  General  Hospital, 
etc.  A  handsome  octavo  volume  of  832  pages,  with  136  relief  and  litho- 
graphic illustrations,  33  of  vi^hich  are  printed  in  colors,  and  all  of  which 
vi^ere  drawn  by  William  J.  Kaula  from  original  specimens.  Prices  :  Cloth, 
^6.00  net;  Half-Morocco,  $7.00  net. 

"Without   Exception,  the  Illustrations    are    the  Best  ever  Seen   in    a 

Work  of  this  Kind. 

"A  most  striking  and  very  excellent  feature  of  this  book  is  its  illustrations.  Without  ex- 
ception, from  the  point  of  accuracy  and  artistic  merit,  they  are  the  best  ever  seen  in  a  work 
of  this  kind.  *  *  *  Many  of  those  representing  microscopic  pictures  are  so  perfect  in  their 
coloring  and  detail  as  almost  to  give  the  beholder  the  impression  that  he  is  looking  down  the 
barrel  of  a  microscope  at  a  well-mounted  section." — Annals  of  Surgery,  Philadelphia. 

"  It  is  the  handsomest  specimen  of  book-making  *  *  *  that  has  ever  been  issued  from  the 
American  medical  press." — American  Journal  of  the  Medical  Sciences,  Philadelphia. 

PATHOLOGY  AND   SURGICAL  TREATMENT   OF  TUMORS. 

By  N.  Senn,  M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Practice  of  Surgery  and 
of  Clinical  Surgery,  Rush  Medical  College;  Professor  of  Surger}%  Chicago 
Polyclinic ;  Attending  Surgeon  to  Presbyterian  Hospital ;  Surgeon-in-Chief, 
St.  Joseph's  Hospital,  Chicago.  One  volume  of  710  pages,  with  515 
engravings,  including  full-page  colored  plates.  Prices:  Cloth,  |6.oo  net; 
Half- Morocco,  ^7.00  net. 

BQoks  specially  devoted  to  this  subject  are  few,  and  in  our  text-books  and 
systems  of  surgery  this  part  of  surgical  pathology  is  usually  condensed  to  a  de- 
gree incompatible  with  its  scientific  and  clinical  importance.  The  author  spent 
many  years  in  collecting  the  material  for  this  work,  and  has  taken  great  pains 
to  present  it  in  a  manner  that  should  prove  useful  as  a  text-book  for  the  student, 
a  work  of  reference  for  the  practitioner,  and  a  reliable  guide  for  the  surgeon. 

"The  most  exhaustive  of  any  recent  book  in  English  on  this  subject.  It  is  well  illus- 
trated, and  will  doubtless  remain  as  the  principal  monograph  on  the  subject  in  our  language 
for  some  years.  The  book  is  handsomely  illustrated  and  printed,  ....  and  the  author  has 
given  a  notable  and  lasting  contribution  to  surgery." — fournal  of  the  American  Medical 
Association,  Chicago. 

LECTURES    ON    RENAL    AND    URINARY    DISEASES.      By 

Robert  Saundby,  M.  D.,  Edin.,  Fellow  of  the  Royal  College  of  Physicians, 
London,  and  of  the  Royal  Medico-Chirurgical  Society;  Physician  to  the 
General  Hospital.  Octavo  volume  of  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.     Cloth,  ^2.50  net. 

"The  volume  makes  a  favorable  impression  at  once.  The  style  is  clear  and  succinct. 
We  cannot  find  any  part  of  the  .subject  in  which  the  views  expressed  are  not  carefully  thought 
out  and  fort  Tied  by  evidence  drawn  from  the  most  recent  sources.  'I'he  book  may  be  cordially 
recommended." — British  Medical  foiirnal. 

"The  work  represents  the  present  knowledge  of  renal  and  urinary  diseases.  It  is  ad- 
mirably written  and  is  accurately  scientific." — Medical  News. 


22  tV.   B.   SAUNDERS' 


A  NEW  PRONOUNCING  DICTIONARY  OF  MEDICINE,  with 
Phonetic  Pronunciation,  Accentuation,  Etymology,  etc.  By  John 
M.  Keating,  M.  D.,  LL.D.,  Fellow  of  the  College  of  Physicians  of  Phila- 
delphia ;  Vice-President  of  the  American  Paediatric  Society ;  Ex-President 
of  the  Association  of  Life  Insurance  Medical  Directors ;  Editor  "  Cyclo- 
paedia of  the  Diseases  of  Children,"  etc.;  and  Henry  Hamilton,  author 
of  "  A  New  Translation  of  Virgil's  M.x\€\&  into  English  Rhyme ;"  co- 
author of  "  Saunders'  Medical  Lexicon,"  etc. ;  with  the  Collaboration  of 
J,  Chalmers  DaCosta,  M.  D.,  and  Frederick  A.  Packard,  M.  D. 
With  an  Appendix  containing  important  Tables  of  Bacilli,  Micrococci, 
Leucomaines,  Ptomaines,  Drugs  and  Materials  used  in  Antiseptic  Sur- 
gery, Poisons  and  their  Antidotes,  Weights  and  Measures,  Thermometric 
Scales,  New  Official  and  Unofficial  Drugs,  etc.  One  very  attractive  volume 
of  over  800  pages.  Second  Revised  Edition.  Prices:  Cloth,  ^5.00  net; 
Sheep  or  Half- Morocco,  ^6.00  net;  with  Denison's  Patent  Ready- Refer- 
ence Index ;  without  patent  index.  Cloth,  $4.00  net ;  Sheep  or  Half- 
Morocco,  $5.00  net. 

PROFESSIOSTAIi  OPIKTIOXS. 

"  I  am  much  pleased  with  Keating's  Dictionary,  and  shall  take  pleasure  in  recommending 
it  to  my  classes." 

Henry  M.  Lyman,  M.  D., 
Professor  of  Principles  and  Practice  of  Medicine,  Rush  Medical  College,  Chicago,  III. 

"  I  am  convinced  that  it  will  be  a  very  valuable  adjunct  to  my  study-table,  convenient  in 
size  and  sufficiently  full  for  ordinary  use." 

C.  A.  LiNDSLEY,  M.  D., 

Professor  of  Theory  and  Practice  of  Medicine,  Medical  Dept.  Yale  University: 

Secretary  Connecticut  State  Board  of  Health,  New  Haven,  Conn^ 


AUTOBIOGRAPHY  OF  SAMUEL  D.  GROSS,  M.  D.,  Emeritus  Pro- 
fessor of  Surgery  in  the  Jefferson  Medical  College  of  Philadelphia,  with 
Reminiscences  of  His  Times  and  Contemporaries.      Edited  by  his  sons, 
Samuel  W.  Gross,  M.  D.,  LL.D.,  late  Professor  of  Principles  of  Surgery 
and  of  Clinical  Surgery  in  the  Jefferson  Medical  College,  and  A.  Haller 
Gross,  A.  M.,  of  the  Philadelphia  Bar.     Preceded  by  a  Memoir  of  Dr. 
Gross,  by  the  late  Austin  Flint,  M.  D.,  LL.D.     In  two  handsome  volumes^ 
each  containing  over  400  pages,  demy  8vo,  extra  cloth,  gilt  tops,  with  fine 
Frontispiece  engraved  on  steel.    Price  per  Volume,  I2.50  net. 
Ihis  autobiography,  which  was  continued  by  the  late  eminent  surgeon  until 
within  three  months  of  his  death,  contains  a  full  and  accurate  history  of  his 
early  struggles,  trials,  and  subsequent  successes,  told  in  a  singularly  interesting 
and  charming  manner,  and  embraces  short  and  graphic  pen-portraits  of  many 
of  the  most  distinguished  men — surgeons,  physicians,  divines,  lawyers,  states- 
men, scientists,  etc. — with  whom  he  was  brought  in  contact  in  America  and  in 
Europe ;  the  whole  forming  a  retrospect  of  more  than  three-quarters  of  a  century. 


CATALOGUE    OF  MEDICAL    WORKS.  23 

PRACTICAL  POINTS  IN  NURSING.  For  Nurses  in  Private 
Practice.  By  Emily  A.  M.  Stonf:y,  Graduate  of  the  Training-School 
for  Nurses,  Lawrence,  Mass. ;  Superintendent  of  the  Training-School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass.  456  pages,  handsomely 
illustrated  with  73  engravings  in  the  text,  and  9  colored  and  half-tone 
plates.     Cloth.     Price,  ^1.75  net. 

SECOND  EDITION,  THOROUGHLY  REVISED. 

In  this  volume  the  author  explains,  in  popular  language  and  in  the  shortest 
possible  form,  the  entire  range  oi  private  nursing  as  distinguished  from  hospital 
nursing,  and  the  nurse  is  instructed  how  best  to  meet  the  various  emergencies  of 
medical  and  surgical  cases  when  distant  from  medical  or  surgical  aid  or  when 
thrown  on  her  own  resources. 

An  especially  valuable  feature  of  the  work  will  be  found  in  the  directions  to 
the  nurse  how  to  improvise  everything  ordinarily  needed  in  the  sick-room,  where 
the  embarrassment  of  the  nurse,  owing  to  the  want  of  proper  appliances,  is  fre- 
quently extreme. 

The  work  has  been  logically  divided  into  the  following  sections : 

I.  The  Nurse  :  her  responsibilities,  qualifications,  equipment,  etc. 
II.  The  Sick-Room :  its  selection,  preparation,  and  management. 

III.  The  Patient :  duties  of  the  nurse  in  medical,  surgical,  obstetric,  and  gyne- 

cologic cases. 

IV.  Nursing  in  Accidents  and  Emergencies. 
V.  Nursing  in  Special  Medical  Cases. 

VI.  Nursing  of  the  New-born  and  Sick  Children. 
VII.  Physiology  and  Descriptive  Anatomy. 

The  Appendix  contains  much  information  in  compact  form  that  will  be  found 
of  great  value  to  the  nurse,  including  Rules  for  Feeding  the  Sick;  Recipes  for 
Invalid  Foods  and  Beverages  ;  Tables  of  Weights  and  Measures ;  Table  for 
Computing  the  Date  of  Labor ;  List  of  Abbreviations ;  Dose-List ;  and  a  full 
and  complete  Glossary  of  Medical  Terms  and  Nursing  Treatment. 

"This  is  a  well-written,  eminently  practical  volume,  which  covers  the  entire  range  of 
private  nursing  as  distinguished  from  hospital  nursing,  and  instructs  the  nurse  how  best  to 
meet  the  various  emergencies  which  may  arise  and  how  to  prepare  everything  ordinarily 
needed  in  the  illness  of  her  patient." — Americayt  Journal  of  Obstetrics  and  Diseases  of 
Wotnen  and  Children,  Aug.,  1896. 

A  TEXT-BOOK  OF  BACTERIOLOGY,  including  the  Etiology  and 
Prevention  of  Infective  Diseases  and  an  account  of  Yeasts  and  Moulds, 
Haematozoa,  and  Psorosperms.  By  Edgar  M.  Crookshank,  M.  B.,  Pro- 
fessor of  Comparative  Pathology  and  Bacteriology,  King's  College,  London. 
A  handsome  octavo  volume  of  700  pages,  with  273  engravings  in  the  text, 
and  22  original  and  colored  plates.     Price,  $6.50  net. 

This  book,  though  nominally  a  Fourth  Edition  of  Professor  Crookshank's 
"  Manual  of  Bacteriology,"  is  practically  a  new  work,  the  old  one  having 
been  reconstructed,  greatly  enlarged,  revised  throughout,  and  largely  rewritten, 
forming  a  text-book  for  the  Bacteriological  Laboratory,  for  Medical  Ofticers  of 
Health,  and  for  Veterinary  Inspectors. 


H  .  IV.  B.   SAUNDERS' 

MEDICAL  DIAGNOSIS.  By  Dr.  Oswald  Vierordt,  Professor  of 
Medicine  at  the  University  of  Heidelberg.  Translated,  with  additions, 
from  the  Fifth  Enlarged  German  Edition,  with  the  author's  permission,  by 
Francis  H.  Stuart,  A.  M.,  M.  D.  In  one  handsome  royal-octavo  volume 
of  600  pnges-  194  fine  wood-cuts  m  the  text,  many  of  them  in  colors. 
Prices:   Cloth,  ^4.00  net ;   Sheep  or  Half-Morocco,  $5.00  net. 

FOURTH  AMERICAN  EDITIOK,  FROM  THE  FIFTH  REVISED  AND 
ENLARGED  GERMAN  EDITION. 

In  this  work,  as  in  no  other  hitherto  published,  are  given  full  and  accurate 
explanations  of  the  phenomena  observed  at  the  bedside.  It  is  distinctly  a  clin- 
ical work  by  a  master  teacher,  characterized  by  thoroughness,  fulness,  and  accu- 
racy. It  is  a  mine  of  information  upon  the  points  that  are  so  often  passed  over 
without  explanation.  Especial  attention  has  been  given  to  the  germ-theory  as  a 
factor  in  the  origin  of  disease. 

The  present  edition  of  this  highly  successful  work  has  been  translated  from 
the  fifth  German  edition.  Many  alterations  have  been  made  throughout  the 
book,  but  especially  in  the  sections  on  Gastric  Digestion  and  the  Nervous  System. 

It  will  be  found  that  all  the  qualities  which  served  to  make  the  earlier  editions 
so  acceptable  have  been  developed  with  the  evolution  of  the  work  to  its  present 
form. 

THE  PICTORIAL  ATLAS  OF  SKIN  DISEASES  AND  SYPHI- 
LITIC AFFECTIONS.  (American  Edition.)  Translation  from 
the  French.  Edited  by  J.  J.  Pringle,  M.  B.,  F.  R.  C.  P.,  Assistant  Phy- 
sician to,  and  Physician  to  the  department  for  Diseases  of  the  Skin  at,  the 
Middlesex  Hospital,  London.  Photo-lithochromes  from  the  famous  models 
of  dermatological  and  syphilitic  cases  in  the  Museum  of  the  Saint-Louis 
Hospital,  Paris,  with  explanatory  wood-cuts  and  letter-press.  In  12  Parts, 
at  ^3.00  per  Part, 

"  Of  all  the  atlases  of  skin  diseases  which  have  been  published  in  recent  years,  the  present 
one  promises  to  be  of  greatest  interest  and  value,  especially  from  the  standpoint  of  the 
general  practitioner." — Afiierican  Medico-Surgical  Bulletin,  Feb.  22,  1896. 

"The  introduction  of  explanatory  wood-cuts  in  the  text  is  a  novel  and  most  important 
feature  which  greatly  furthers  the  easier  understanding  of  the  excellent  plates,  than  which 
nothing,  we  venture  to  say,  has  been  seen  better  in  point  of  correctness,  beauty,  and  general 
merit." — New  York  Medical  Journal,  Feb.  15,  1896. 

"  An  interesting  feature  of  the  Atlas  is  the  descriptive  text,  which  is  written  for  each  picture 
by  the  physician  who  treated  the  case  or  at  whose  instigation  the  models  have  been  made. 
We  predict  for  this  truly  beautiful  work  a  large  circulation  in  all  parts  of  the  medical  world 
where  the  names  St.  Louis  and  Baretta  have  preceded  it." — Medical  Record,  N.  Y.,  Feb.  i, 
1896. 

A  TEXT-BOOK  OF  MECHANO-THERAPY  (MASSAGE  AND 
MEDICAL  GYMNASTICS).  By  Axel  V.  Grafstrom,  B.  Sc, 
M.  D.,  late  Lieutenant  in  the  Royal  Swedish  Army;  late  House  Physi- 
cian, City  Hospital,  Blackwell's  Island,  New  York.  i2mo,  139  pages, 
illustrated.     Cloth,  ^i.oo  net. 


CATALOGUE    OP  MEDICAL    WORKS.  2 5 

DISEASES  OF  THE  EYE.  A  Hand-Book  of  Ophthalmic  Prac- 
tice. By  G.  E.  DE  SCHWEINITZ,  M.  D.,  Professor  of  Ophthalmology  in 
the  Jefferson  Medical  College,  Philadelphia,  etc.  A  handsome  royal- 
octavo  volume  of  696  pages,  wiih  255  fine  illustrations,  many  of  which  are 
original,  and  2  chromo-lithographic  plates.  Prices :  Cloth,  $4.00  net ; 
Sheep  or  Half-Morocco,  ^5.00  net. 

THIRD  EDITION,  THOROUGHLY  REVISED. 

In  the  third  edition  of  this  text-book,  destined,  it  is  hoped,  to  meet  the  favor- 
able reception  which  has  been  accorded  to  its  predecessors,  the  work  has  been 
revised  thoroughly,  and  much  new  matter  has  been  introduced.  Particular 
attention  has  been  given  to  the  important  relations  which  micro-organisms  bear 
to  many  ocular  diseases.  A  number  of  special  paragraphs  on  new  subjects  have 
been  introduced,  and  certain  articles,  including  a  portion  of  the  chapter  on 
Operations,  have  been  largely  rewritten,  or  at  least  materially  changed.  A 
number  of  new  illustrations  have  been  added.  The  Appendix  contains  a  full 
description  of  the  method  of  determining  the  corneal  astigmatism  with  the 
ophthalmometer  of  Javal  and  Schiotz,  and  the  rotation  of  the  eyes  with  the 
tropometer  of  Stevens. 

"A  work  that  will  meet  the  requirements  not  only  of  the  specialist,  but  of  the  general 
practitioner  in  a  rare  degree.     I  am  satisfied  that  unusual  success  awaits  it." 

William  Pepper,  M.  D. 

Provost  and  Professor  of  Theory  and  Practice  of  Medicine  and  Clinical  Medicine 

in  the  University  of  Pennsylvania. 

"A  clearly  written,  comprehensive  manual.  .  .  .  One  which  we  can  commend  to  students 
as  a  reliable  text-book,  written  with  an  evident  knowledge  of  the  wants  of  those  entering  upon 
the  study  of  this  special  branch  of  medical  science/' — British  Medical  Journal. 

"  It  is  hardly  too  much  to  say  that  for  the  student  and  practitioner  beginning  the  study  of 
Ophthalmology,  it  is  the  best  single  volume  at  present  published." — Medical  News. 

"  It  is  a  very  useful,  satisfactory,  and  safe  giiide  for  the  student  and  the  practitioner,  and 
one  of  the  best  works  of  this  scope  in  the  English  language." — Annals  of  Ophthalmology. 

DISEASES  OF  WOMEN.     By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant 

Surgeon  to  Middlesex  Hospital,  and  Surgeon  to  Chelsea  Hospital,  London  ; 

and  Arthur  E.  Giles,  M.  D.,  B.  Sc,  Lond.,  F.R.C.  S.,  Edin.,  Assistant 

,      Surgeon  to  Chelsea  Hospital,  London.     436  pages,  handsomely  illustrated. 

Cloth,  ^2.50  net. 

The  authors  have  placed  in  the  hands  of  the  physician  and  student  a  concise 
yet  comprehensive  guide  to  the  study  of  gynecology  in  its  most  modern  develop- 
ment. It  has  been  their  aim  to  relate  facts  and  describe  methods  belonging  to 
the  science  and  art  of  gynecology  in  a  way  that  will  prove  useful  to  students  for 
examination  purposes,  and  which  will  also  enable  the  general  physician  to  prac- 
tice this  important  department  of  surgery  with  advantage  to  his  patients  and  with 
satisfaction  to  himftelf. 

"  The  book  is  very  well  prepared,  and  is  certain  to  be  well  received  by  the  medical  public." 
— British  Medical  Journal. 

"The  text  has  been  carefully  prepared.  Nothing  essential  has  been  omitted,  and  its 
teachings  are  those  recommended  by  the  leading  authorities  of  the  A'^y."— Journal  of  the 
American  Medical  Association. 


26  Pi^.  B.  SAUNDEkS' 


TEXT-BOOK  UPON  THE  PATHOGENIC  BACTERIA.  Spe- 
cially written  for  Students  of  Medicine.  By  Joseph  McFarland, 
M.  D.,  Professor  of  Pathology  and  Bacteriology  in  the  Medico-Chirurgical 
College  of  Philadelphia,  etc,  497  pages,  finely  illustrated.  Price,  Cloth, 
$2.50  net. 

SECOND  EDITION,  REVISED  AND  GREATLY  ENLARGED. 
The  work  is  intended  to  be  a  text-book  for  the  medical  student  and  for  the 
practitioner  who  has  had  no  recent  laboratory  training  in  this  department  of  medi- 
cal science.  The  instructions  given  as  to  needed  apparatus,  cultures,  stainings, 
microscopic  examinations,  etc.  are  ample  for  the  student's  needs,  and  will  afford 
to  the  physician  much  information  that  will  interest  and  profit  him  relative  to  a 
subject  which  modern  science  shows  to  go  far  in  explaining  the  etiology  of  many 
diseased  conditions. 

In  this  second  edition  the  work  has  been  brought  up  to  date  in  all  depart- 
ments of  the  subject,  and  numerous  additions  have  been  made  to  the  technique 
in  the  endeavor  to  make  the  book  fulfil  the  double  purpose  of  a  systematic  work 
upon  bacteria  and  a  laboratory  guide. 

"  It  is  excellently  adapted  for  the  medical  students  and  practitioners  for  whom  it  is  avowedly- 
written.  .  .  .  The  descriptions  given  are  accurate  and  readable,  and  the  book  should  prove 
useful  to  those  for  whom  it  is  written. — Londoii  Lajtcet,  Aug.  29,  1896. 

"  The  author  has  succeded  admirably  in  presenting  the  essential  details  of  bacteriological 
technics,  together  with  a  judiciously  chosen  summary  of  our  present  knowledge  of  pathogenic 
bacteria.  .  .  .  The  work,  we  think,  should  have  a  wide  circulation  among  English-speaking 
students  of  medicine." — iV^.  Y.  Medical  Journal,  April  4,  1896. 

"  The  book  will  be  found  of  considerable  use  by  medical  men  who  have  not  had  a  special 
bacteriological  training,  and  who  desire  to  understand  this  important  branch  of  medical 
science." — Edinburgh  Medical  Journal,  July,  1896. 

LABORATORY    GUIDE    FOR    THE    BACTERIOLOGIST.      By 

Langdon  Frothingham,  M.  D.  V.,  Assistant  in  Bacteriology  and  Veteri- 
nary Science,  Sheffield  Scientific  School,  Yale  University.  Illustrated. 
Price,  Cloth,  75  cents. 

The  technical  methods  involved  in  bacteria-culture,  methods  of  staining,  and 
microscopical  study  are  fully  described  and  arranged  as  simply  and  concisely  as 
possible.     The  book  is  especially  intended  for  use  in  laboratory  work. 

"  It  is  a  convenient  and  useful  little  work,  and  will  more  than  repay  the  outlay  necessary 
for  its  purchase  in  the  saving  of  time  which  would  otherwise  be  consumed  in  looking  up  the 
various  points  of  technique  so  clearly  and  concisely  laid  down  in  its  pages." — Avierican  Med.- 
Surg.  Bulletin. 

FEEDING  IN  EARLY  INFANCY.  By  Arthur  V.  Meigs,  M.  D. 
Bound  in  limp  cloth,  flush  edges.     Price,  25  cents  net. 

Synopsis  :  Analyses  of  Milk — Importance  of  the  Subject  of  Feeding  in  Early 
Infancy — Proportion  of  Casein  and  Sugar  in  Human  Milk — Time  to  Begin  Arti- 
ficial Feeding  of  Infants — Amount  of  Food  to  be  Administefed  at  Each  Feed- 
ing— Intervals  between  Feedings — Increase  in  Amount  of  Food  at  Different 
Periods  of  Infant  Development — Unsuitableness  of  Condensed  Milk  as  a  Sub- 
stitute for  Mother's  Milk — Objections  to  Sterilization  or  "Pasteurization"  of 
Milk — Advances  made  in  the  Method  of  Artificial  Feeding  of  Infants. 


CATALOGUE    OF  MEDICAL    WORKS.  2/ 

MATERIA  MEDICA  FOR  NURSES.  By  Emily  A.  M.  Stoney, 
Graduate  of  the  Training-school  for  Nurses,  Lawrence,  Mass. ;  late 
Superintendent  of  the  Training-school  for  Nurses,  Carney  Hospital,  South 
Boston,  Mass.     Handsome  octavo,  300  pages.     Cloth,  $1.50  net. 

The  present  book  differs  from  other  similar  works  in  several  features,  all  of 
which  are  introduced  to  render  it  more  practical  and  generally  useful.  The 
general  plan  of  contents  follows  the  lines  laid  down  in  training-schools  for 
nurses,  but  the  book  contains  much  useful  matter  not  usually  included  in  works 
of  this  character,  such  as  Poison-emergencies,  Ready  Dose-list,  Weights  and 
Measures,  etc.,  as  well  as  a  Glossary,  defining  all  the  terms  in  Materia  Medica, 
and  describing  all  the  latest  drugs  and  remedies,  which  have  been  generally 
neglected  by  other  books  of  the  kind. 

ESSENTIALS  OF  ANATOMY  AND  MANUAL  OF  PRACTI- 
CAL DISSECTION,  containing  "  Hints  on  Dissection."  By  Charles 
B.  Nancrede,  M.  D.,  Professor  of  Surgery  and  Clinical  Surgery  in  the 
University  of  Michigan,  Ann  Arbor;  Corresponding  Member  of  the  Royal 
Academy  of  Medicine,  Rome,  Italy;  late  Surgeon  Jefferson  Medical  Col- 
lege, etc.  Fourth  and  revised  edition.  lost  8vo,  over  500  pages,  with 
handsome  full-page  lithographic  plates  in  colors,  and  over  200  illustrations. 
Price  :  Extra  Cloth  or  Oilcloth  for  the  dissection-room,  $2.00  net. 

Neither  pains  nor  expense  has  been  spared  to  make  this  work  the  most  ex- 
haustive yet  concise  Student's  Manual  of  Anatomy  and  Dissection  ever  pub- 
lished, either  in  America  or  in  Europe. 

The  colored  plates  are  designed  to  aid  the  student  in  dissecting  the  muscles 
arteries,  veins,  and  nerves.  The  wood-cuts  have  all  been  specially  drawn  and 
engraved,  and  an  Appendix  added  containing  60  illustrations  representing  the 
structure  of  the  entire  human  skeleton,  the  w^hole  being  based  on  the  eleventh 
edition  of  Gray's  Anatomy, 

A  MANUAL  OF  PRACTICE  OF  MEDICINE.  By  A.  A.  Stevens, 
A.  M.,  M.  D.,  Instructor  in  Physical  Diagnosis  in  the  University  of  Penn- 
sylvania, and  Professor  of  Pathology  in  the  Woman's  Medical  College  of 
Pennsylvania.  Specially  intended  for  students  preparing  for  graduation 
and  hospital  examinations.  Post  8vo,  519  pages.  Numerous  illustrations 
and  selected  formulae.     Price,  bound  in  flexible  leather,  ^2.00  net. 

FIFTH  EDITION,  REVISED  AND  ENLARGED. 

Contributions  to  the  science  of  medicine  have  poured  in  so  rapidly  during  the 
last  quarter  of  a  century  that  it  is  well-nigh  impossible  for  the  student,  with  the 
limited  time  at  his  disposal,  to  master  elaborate  treatises  or  to  cull  from  them 
that  knowledge  which  is  absolutely  essential.  P>om  an  extended  experience  in 
teaching,  the  author  has  been  enabled,  by  classification,  to  group  allied  symp- 
toms, and  by  the  judicious  elimination  of  theories  and  redundant  explanations 
to  bring  within  a  comparatively  small  compass  a  complete  outline  of  the  prac- 
tice of  medicine. 


28  tV.  B.   SAUNDERS' 


MANUAL    OF    MATERIA    MEDICA    AND    THERAPEUTICS. 

By  A.  A.  Stevens,  A.  M.,  M.  D.,  Instructor  of  Physical  Diagnosis  in  the 
University  of  Pennsylvania,  and  Professor  of  Pathology  in  the  Woman's 
Medical  College  of  Pennsylvania.  445  pages.  Price,  bound  in  flexible 
leather,  $2.25. 

SECOND   EDITION,    REVISED. 

This  wholly  new  volume,  which  is  based  on  the  last  edition  of  the  Pharma- 
copxia,  comprehends  the  following  sections  :  Physiological  Action  of  Drugs ; 
Drugs;  Remedial  Measures  other  than  Drugs;  Applied  Therapeutics;  Incom- 
patibility  in  Prescriptions;  Table  of  Doses;  Index  of  Drugs;  and  Index  of 
Diseases ;  the  treatment  being  elucidated  by  more  than  two  hundred  formulae. 

"  The  author  is  to  be  congratulated  upon  having  presented  the  medical  student  with  as 
accurate  a  manual  of  therapeutics  as  it  is  possible  to  prepare." —  Therapeutic  Gazette. 

"  Far  superior  to  most  of  its  class  ;  in  fact,  it  is  very  good.  Moreover,  the  book  is  reliable 
and  accurate." — New  York  Medical  Journal. 

"  The  author  has  faithfully  presented  modern  therapeutics  in  a  comprehensive  work,  .  .  . 
and  it  will  be  found  a  reliable  guide." —  University  Medical  Magazine. 

NOTES  ON  THE  NEWER  REMEDIES:    their  Therapeutic  Ap- 
plications and  Modes  of  Administration.     By  David  Cerna,  M.  D., 
.     Ph.  D.,  Demonstrator  of  and  Lecturer  on  Experimental  Therapeutics  in 
the  University  of  Pennsylvania.     Post-octavo,  253  pages.     Price,  ^1.25. 

SECOND  EDITION,  RE-WRITTEN  AND  GREATLY   ENLARGED. 

The  work  takes  up  in  alphabetical  order  all  the  newer  remedies,  giving  their 
physical  properties,  solubility,  therapeutic  applications,  administration,  and 
chemical  formula. 

It  thus  forms  a  very  valuable  addition  to  the  various  works  on  therapeutics 
now  in  existence. 

Chemists  are  so  multiplying  compounds,  that^  if  each  compound  is  to  be  thor- 
oughly studied,  investigations  must  be  carried  far  enough  to  determine  the  prac- 
tical importance  of  the  new  agents. 

"  Especially  valuable  because  of  its  completeness,  its  accuracy,  its  systematic  consider- 
ation of  the  properties  and  therapy  of  many  remedies  of  which  doctors  generally  know  but 
little,  expressed  in  a  brief  yet  terse  manner." — Chicago  Clinical  Review. 


TEMPERATURE  CHART.     Prepared  by  D.  T.  Laine,  M.  D.      Size 
8x  13^  inches.     Price,  per  pad  of  25  charts,  50  cents. 

A  conveniently  arranged  chart  for  recording  Temperature,  with  columns  for 
daily  amounts  of  Urinary  and  Fecal  Excretions,  Food,  Remarks,  etc.  On  the 
back  of  each  chart  is  given  in  full  the  method  of  Brand  in  the  treatment  of 
Typhoid  Fever. 


CATALOGUE    OF  MEDICAL    WORKS.  29 

A  TEXT-BOOK  OF  HISTOLOGY,  DESCRIPTIVE  AND  PRAC- 
TICAL. For  the  Use  of  Students.  By  Arthur  Clarkson,  M.  B., 
C.  M.,  Edin.,  formerly  Demonstrator  of  Physiology  in  the  Owen's  College, 
Manchester;  late  Demonstrator  of  Physiology  in  the  Yorkshire  College, 
Leeds.  Large  8vo,  554  pages,  with  22  engravings  in  the  text,  and  174 
beautifully  colored  original  illustrations.  Price,  strongly  bound  in  Cloth, 
^6.00  net. 

The  purpose  of  the  writer  in  this  work  has  been  to  furnish  the  student  of  His- 
tology, in  one  volume,  v/iih  both  the  descriptive  and  the  practical  part  of  the 
science.  The  first  two  chapters  are  devoted  to  the  consideration  of  the  genera] 
methods  of  Histology ;  subsequently,  in  each  chapter,  the  structure  of  the  tissue 
or  organ  is  first  systematically  described,  the  student  is  then  taken  tutorially  over 
the  specimens  illustrating  it,  and,  finally,  an  appendix  affords  a  short  note  of  the 
methods  of  preparation. 

"  The  work  must  be  considered  a  valuable  addition  to  the  list  of  available  text-books,  and 
is  to  be  highly  recommended." — New  York  Medical  Journal. 

"  One  of  the  best  works  for  students  we  have  ever  noticed.  We  predict  that  the  book  will 
attain  a  well-deserved  popularity  among  our  students." — Chicago  Medical  Recorder. 


THE  PATHOLOGY  AND  TREATMENT  OF  SEXUAL  IM- 
POTENCE. By  Victor  G.  Vecki,  M.  D.  From  the  second  Ger- 
man edition,  revised  and  rewritten.  Demi-octavo,  about  300  pages. 
Cloth,  ^2.00  net. 

Just  Issued, 

The  subject  of  impotence  has  but  seldom  been  treated  in  this  country  in  the 
truly  scientific  spirit  that  it  deserves,  and  this  volume  will  come  to  many  as  a 
revelation  of  the  possibilities  of  therapeusis  in  this  important  field.  Dr.  Vecki's 
work  has  long  been  favorably  known,  and  the  German  book  has  received  the 
highest  consideration.  This  edition  is  more  than  a  mere  translation,  for,  although 
based  on  the  German  edition,  it  has  been  entirely  rewritten  by  the  author  in 
English. 

ARCHIVES  OF  CLINICAL  SKIAGRAPHY.  By  Sydney  Rowland, 
B.  A.,  Camb.  A  series  of  collotype  illustrations,  with  descriptive  text, 
illustrating  the  applications  of  the  New  Photography  to  Medicine  and  Sur- 
gery.    Price,  per  Part,  $1.00.      Parts  I.  to  V.  now  ready. 

The  object  of  this  publication  is  to  put  on  record  in  permanent  form  some  of 
the  most  striking  applications  of  the  new  photography  to  the  needs  of  Medicine 
and  Surgery. 

The  progress  of  this  new  art  has  been  so  rapid  that,  although  Prof.  Rontgen's 
discovery  is  only  a  thing  of  yesterday,  it  has  already  taken  its  place  among  the 
approved  and  accepted  aids  to  diagnosis, 


30  W.   B.   SAUNDERS' 


DISEASES  OF  WOMEN.  By  Henry  J.  Garrigues,  A.M.,  M.  D., 
Professor  of  Gynecology  in  the  New  York  School  of  Clinical  Medicine ; 
Gynecologist  to  St.  Mark's  Hospital  and  to  the  German  Dispensary,  New- 
York  City.  In  one  handsome  octavo  volume  of  728  pages,  illustrated  by 
335  engravings  and  colored  plates.  Prices:  Cloth,  ^4.00  net;  Sheep  or 
Half-Morocco,  ^5.00  net, 

A  PRACTICAL  work  on  gynecology  for  the  use  of  students  and  practitioners, 
written  in  a  terse  and  concise  manner.  The  importance  of  a  thorough  know- 
ledge of  the  anatomy  of  the  female  pelvic  organs  has  been  fully  recognized  by 
the  author,  and  considerable  space  has  been  devoted  to  the  subject.  The  chap- 
ters on  Operations  and  on  Treatment  are  thoroughly  modern,  and  are  based 
upon  the  large  hospital  and  private  practice  of  the  author.  The  text  is  eluci- 
dated by  a  large  number  of  illustrations  and  colored  plates,  many  of  them  being 
original,  and  forming  a  complete  atlas  for  studying  emb)yolog}'  and  the  anatomy 
of  \\\&  female  genitalia,  besides  exemplifying,  whenever  needed,  morbid  condi- 
tions, instruments,  apparatus,  and  operations. 

Second  Edition^  Thoroughly  Revised, 

The  first  edition  of  this  work  rnet  with  a  most  appreciative  reception  by  the 
medical  press  and  profession  both  in  this  country  and  abroad,  and  was  adopted 
as  a  text-book  or  recommended  as  a  book  of  reference  by  nearly  one  hzmdred 
colleges  in  the  United  States  and  Canada.  The  author  has  availed  himself  of 
the  opportunity  afforded  by  this  revision  to  embody  the  latest  approved  advances 
in  the  treatment  employed  in  this  important  branch  of  Medicine.  He  has  also 
more  extensively  expressed  his  own  opinion  on  the  comparative  value  of  the 
different  methods  of  treatment  employed. 

"One  of  the  best  text-books  for  students  and  practitioners  which  has  been  published  in 
the  English  language;  it  is  condensed,  clear,  and  comprehensive.  The  profound  learning 
and  great  clinical  experience  of  the  distinguished  author  find  expression  in  this  book  in  a 
most  attractive  and  instructive  form.  Young  practitioners,  to  whom  experienced  consultants 
may  not  be  available,  will  find  in  this  book  invaluable  counsel  and  help." 

Thad.  a.  Reamy,  M.  D.,  LL.D., 

Professor  of  Clinical  Gynecology ,  Medical  College  of  Ohio ;   Gynecologist  to  the  Good 

Samaritan  and  Cincinnati  Hospitals. 


K  SYLLABUS  OF  GYNECOLOGY,  arranged  in  conformity  with 
"An  American  Text-Book  of  Gynecology."  By  J.  W.  Long,  M.  D., 
Professor  of  Diseases  of  Women  and  Children,  Medical  College  of  Vir- 
ginia, etc.     Price,  Cloth  (interleaved),  $1.00  net. 

Based  upon  the  teaching  and  methods  laid  down  in  the  larger  work,  this  will 
not  only  be  useful  as  a  supplementary  volume,  but  to  those  who  do  not  already 
possess  the  text-book  it  will  also  have  an  independent  value  as  an  aid  to  the 
practitioner  in  gynecological  work,  and  to  the  student  as  a  guide  in  the  lecture- 
room,  as  the  subject  is  rnesented  in  a  manner  at  once  systematic,  clear,  succinct, 
pnd  practical. 


CATALOGUE    OF  MEDICAL    WORKS.  3 1 


THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited 
by  W.  A.  Newman  Borland,  M.  D.,  Assistant  Obstetrician  to  the  Hospital 
of  the  University  of  Pennsylvania ;  Fellow  of  the  American  Academy  of 
Medicine.  Containing  the  pronunciation  and  definition  of  over  26,000 
words  used  in  medicine  and  the  kindred  sciences,  with  64  extensive  tables. 
Handsomely  bound  in  flexible  leather,  limp,  with  gold  edges.  Price, 
^1.25  net. 

Over  26,000  Words,  64  Valuable  Tables, 

This  is  the  ideal  pocket  lexicon.  It  is  an  absolutely  new  book,  and  not  a  re- 
vision of  any  old  work.  It  is  complete,  defining  all  the  terms  of  modern  medi- 
cine and  forming  a  vocabulary  of  over  26,000  words.  It  gives  the  pronunciation 
of  all  the  terms.  It  makes  a  special  feature  of  the  newer  words  neglected  by 
other  dictionaries.  It  contains  a  wealth  of  anatomical  tables  of  special  value  to 
students.     It  forms  a  handy  volume,  indispensable  to  every  medical  man. 

SAUNDERS'  POCKET  MEDICAL  FORMULARY.  By  William 
M.  Powell,  M.  D.,  Attending  Physician  to  the  Mercer  House  for  Invalid 
Women  at  Atlantic  City.  Containing  1800  Formulae,  selected  from  several 
hundred  of  the  best-known  authorities.  Forming  a  handsome  and  con- 
venient pocket  companion  of  nearly  300  printed  pages,  with  blank  leaves 
for  Additions;  with  an  Appendix  containing  Posological  Table,  Formulae 
and  Doses  for  Hypodermatic  Medication,  Poisons  and  their  Antidotes, 
Diameters  of  the  Pemale  Pelvis  and  Foetal  Head,  Obstetrical  Table,  Diet 
List  for  Various  Diseases,  Materials  and  Drugs  used  in  Antiseptic  Surgery, 
Treatment  of  Asphyxia  from  Drowning,  Surgical  Remembrancer,  Tables 
of  Incompatibles,  Eruptive  Fevers,  Weights  and  Measures,  etc.  Hand- 
somely bound  in  morocco,  with  side  index,  wallet,  and  flap.  Price,  ^1.75 
net. 

FIFTH  EDITION,  THOROUGHLY  REVISED. 

"This  little  book,  that  can  be  conveniently  carried  in  the  pocket,  contains  an  immense 
amount  of  material.  It  is  very  useful,  and  as  the  name  of  the  author  of  each  prescription  is 
given, is  unusually  reliable." — New  York  Medical  Record. 

A  COMPENDIUM  OF  INSANITY.  By  John  B.  Chapin,  M.D.,  LL.D., 
Physician-in-Chief,  Pennsylvania  Hospital  for  the  Insane;  late  Physician- 
Superintendent  of'the  Willard  State  Hospital,  New  York;  Honorary  Mem- 
ber of  the  Medico-Psychological  Society  of  Great  Britain,  of  the  Society  of 
Mental  Medicine  of  Belgium.      l2mo,  234  pages,  illust.     Cloth,  ^1.25  net. 

The  author  has  given,  in  a  condensed  and  concise  form,  a  compendium  of 
Diseases  of  the  Mind,  for  the  convenient  use  and  aid  of  physicians  and  students. 
It  contains  a  clear,  conci.se  statement  of  the  clinical  aspects  of  the  various  ab- 
normal mental  conditions,  with  directions  as  to  the  most  approved  methods  of 
managing  and  treating  the  insane. 

"  The  practical  parts  of  Dr.  Chapin's  book  are  what  constitute  its  distinctive  merit.  AVe 
desire  especially,  however,  to  call  attention  to  the  fact  that  in  the  subject  of  the  therapeutics 
of  insanity  the  work  is  exceedingly  valuable.  The  author  has  made  a  distinct  addition  to  the 
literature  of  his  specialty." — Philadelphia  Medical  Journal. 


32  W.   B,    SAUNDERS' 


AN  OPERATION  BLANK,  with  Lists  of  Instruments,  etc.  re- 
quired in  Various  Operations.  Prepared  by  W.  W.  Keen,  M.  D., 
LL.D.,  Professor  of  Principles  of  Surgery  in  the  Jefferson  Medical  Col- 
lege, Philadelphia.  Price  per  Pad,  containing  Blanks  for  fifty  operations, 
50  cents  net. 

SECOND  EDITION,  REVISED  FORM. 

A  convenient  blank,  suitable  for  all  operations,  giving  complete  instructions 
regarding  necessary  preparation  of  patient,  etc.,  with  a  full  list  of  dressings  and 
medicines  to  be  employed. 

On  the  back  of  each  blank  is  a  list  of  instruments  used  —  viz.  general  instru 
ments,  etc.,  required  for  all  operations;  and  special  instruments  for  surgery  of 
the  brain  and  spine,   mouth  and  throat,   abdomen,   rectum,  male   and  female 
genito-urinary  organs,  the  bones,  etc. 

The  whole  forming  a  neat  pad,  arranged  for  hanging  on  the  wall  of  a  sur- 
geon's office  or  in  the  hospital  operating-room. 

"Will  serve  a  useful  purpose  for  the  surgeon  in  reminding  him  of  the  details  of  prepa- 
ration for  the  patient  and  the  room  as  well  as  for  the  instruments,  dressings,  and  antiseptics 
needed  " — AVw  Vo?  k  iMedical  Record 

"  Covers  about  all  that  can  be  needed  in  any  operation." — American  Lancet. 

"  The  plan  is  a  capital  one." — Boston  Medical  and  Surgical  journal. 

LABORATORY  EXERCISES  IN  BOTANY.  By  Edson  S.  Bastin, 
M.  A.,  Professor  of  Materia  Medica  and  Botany  in  the  Philadelphia  Col- 
lege of  Phannacy.  Octavo  volume  of  536  pages,  87  full-page  plates.  Price, 
Cloth,  ^2.50. 

This  work  is  intended  for  the  beginner  and  the  advanced  student,  and  it  fully 
covers  the  structure  of  flowering  plants,  roots,  ordinary  stems,  rhizomes,  tubers, 
bulbs,  leaves,  flowers,  fruits,  and  seeds.  Particular  attention  is  given  to  the  gross 
and  microscopical  structure  of  plants,  and  to  those  used  in  medicine.  Illustra- 
tions have  freely  been  used  to  elucidate  the  text,  and  a  complete  index  to  facil- 
itate reference  has  been  added. 

"  There  is  no  work  like  it  in  the  pharmaceutical  or  botanical  literature  of  this  country,  and 
we  predict  for  it  a  wide  circulation." — American  yournal  of  Pharmacy. 

DIET  IN  SICKNESS  AND  IN  HEALTH.  By  Mrs.  Ernest  Hart, 
formerly  Student  of  the  Faculty  of  Medicine  of  Paris  and  of  the  London 
School  of  Medicine  for  Women ;  with  an  INTRODUCTION  by  Sir  Heniy 
Thompson,  F.  R.  C.  S.,  M.  D.,  London.  220  pages;  illustrated.  Price, 
Cloth,  ^1.50. 

Useful  to  those  who  have  to  nurse,  feed,  and  prescribe  for  the  sick.  In 
each  case  the  accepted  causation  of  the  disease  and  the  reasons  for  the  special 
diet  prescribed  are  briefly  described.  Medical  men  will  find  the  dietaries  and 
recipes  practically  useful,  and  likely  to  save  them  trouble  in  directing  the  dietetic 
treatment  of  patieritg. 


CATALOGUE    OF  MEDICAL    WORKS.  l'^ 

M    MANUAL    OF    PHYSIOLOGY,  with    Practical    Exercises.     For 

Students  and  Practitioners.    By  G.  N.  Stewart,  M.  A.,  M.  D.,  D.  Sc, 

lately  Examiner  in  Physiology,  University  of  Aberdeen,  and  of  the  New 

Museums,  Cambridge  University ;  Professor  of  Physiology  in  the  Western 

Reserve  University,  Cleveland,  Ohio.     Handsome  octavo  volume  of  848 

pages,  with  300  illustrations  in  the  text,  and  5  colored  plates.    Price,  Cloth, 

^3.75  net. 

THIRD  EDITION,  REVISED. 

"  It  will  make  its  way  by  sheer  force  of  merit,  and  amply  deserves  to  do  so.  It  is  one  oj 
the  very  best  English  text-books  on  the  subject." — London  Lancet. 

"  Of  the  many  text-books  of  physiology  published,  we  do  not  know  of  one  that  so  nearly 
comes  up  to  the  ideal  as  does  Professor  Stewart's  volume." — British  Medical  Journal. 

ESSENTIALS  OF  PHYSICAL  DIAGNOSIS  OF  THE  THORAX. 

By  Arthur  M.  Corwin,  A.  M.,  M.  D.,  Demonstrator  of  Physical  Diagno- 
sis in  the  Rush  Medical  College,  Chicago;  Attending  Physician  to  the 
Central  Free  Dispensary,  Department  of  Rhinology,  Laryngology,  and 
Diseases  of  the  Chest.  200  pages.  Illustrated.  Cloth,  flexible  covers. 
Price,  ^1,25  net. 

SYLLABUS  OF  OBSTETRICAL  LECTURES  in  the  Medical 
Department,  University  of  Pennsylvania.  By  Richard  C.  Norris, 
A.  M.,  M.  D.,  Lecturer  on  Clinical  and  Operative  Obstetrics,  University 
of  Pennsylvania.  Third  edition,  thoroughly  revised  and  enlarged.  Crown 
8vo.     Price,  Cloth,  interleaved  for  notes,  ^2.00  net. 

"  This  work  is  so  far  superior  to  others  on  the  same  subject  that  we  take  pleasure  in  call- 
ing attention  briefly  to  its  excellent  features.  It  covers  the  subject  thoroughly,  and  will 
prove  invaluable  both  to  the  student  and  the  practitioner.  The  author  has  introduced  a 
number  of  valuable  hints  which  would  only  occur  to  one  who  was  himself  an  experienced 
teacher  of  obstetrics.  The  subject-matter  is  clear,  forcible,  and  modern.  We  are  especially 
pleased  with  the  portion  devoted  to  the  practical  duties  of  the  accoucheur,  care  of  the  child, 
etc.  The  paragraphs  on  antiseptics  are  admirable;  there  is  no  doubtful  tone  in  the  direc- 
tions given.  No  details  are  regarded  as  unimportant;  no  minor  matters  omitted.  We  ven- 
ture to  say  that  even  the  old  practitioner  will  find  useful  hints  in  this  direction  which  he  can- 
not afford  to  despise." — New  York  Medical  Record. 

A  SYLLABUS  OF  LECTURES  ON  THE  PRACTICE  OF  SUR- 
GERY, arranged  in  conformity  with  *' An  American  Text-Book 
of  Surgery."  By  N.  Senn,  M.  D,,  Ph.  D.,  Professor  of  Surgery  in  Rush 
Medical  College,  Chicago,  and  in  the  Chicago  Polyclinic.     Price,  $2.00. 

This  work  by  so  eminent  an  author,  himself  one  of  the  contributors  to 
"  An  American  Text-Book  of  Surgery,"  will  prove  of  exceptional  value  to 
the  advanced  student  who  has  adopted  that  work  as  his  text-book.  It  is  not 
only  the  syllabus  of  an  unrivalled  course  of  surgical  practice,  but  it  is  also  an 
epitome  of  or  supplement  to  the  larger  work. 

"  The  author  has  evidently  spared  no  pains  in  making  his  Syllabus  thoroughly  comprehen- 
sive, and  har.  added  new  matter  and  alluded  to  the  most  recent  authors  and  operations.  Full 
references  are  also  given  to  all  requisite  details  of  surgical  anatomy  and  pathology." — Brititk 
Medical  Journal ,  London. 


34  ^   B.   SAUNDERS' 


THE  CARE  OF  THE  BABY.  By  J.  P.  Crozer  Griffith,  M.  D., 
Clinical  Professor  of  Diseases  of  Children,  University  of  Pennsylvania; 
Physician  to  the  Children's  Hospital',  Philadelphia,  etc.  404  pages,  with 
67  illustrations  in  the  text,  and  5  plates.      i2mo.     Price,  $1.50. 

SECOND  EDITION,  REVISED. 

A  reliable  guide  not  only  for  mothers,  but  also  for  medical  students  and 
practitioners  whose  opportunities  for  observing  children  have  been  limited. 

"  The  whole  book  is  characterized  by  rare  good  sense,  and  is  evidently  written  by  a  mas- 
ter hand.  _  It  can  be  read  with  benefit  not  only  by  mothers,  but  by  medical  students  and  by 
iny  practitioners  who  have  not  had  large  opportunities  for  observing  children."— ^;.'/5r/ca« 
ymrnal  of  Obstetrics. 

THE  NURSE'S  DICTIONARY  of  Medical  Terms  and  Nursing 
Treatment,  containing  Definitions  of  the  Principal  Medical  and  Nursing 
Terms,  Abbreviations,  and  Physiological  Names,  and  Descriptions  of  the 
Instruments,  Drugs,  Diseases,  Accidents,  Treatments,  Operations,  Foods, 
Appliances,  etc.  encountered  in  the  ward  or  the  sick-room.  By  Honnor 
Morten,  author  of  "How  to  Become  a  Nurse,"  "Sketches  of  Hospital 
Life,"  etc.     i6mo,  140  pages.     Price,  Cloth,  ^i.oo. 

This  little  volume  is  intended  for  use  merely  as  a  small  reference-book  which 
can  be  consulted  at  the  bedside  or  in  the  ward.  It  gives  sufficient  explanation 
to  the  nurse  to  enable  her  to  comprehend  a  case  until  she  has  leisure  to  look  up 
larger  and  fuller  works  on  the  subject. 

DIET  LISTS  AND  SICK-ROOM  DIETARY.  By  Jerome  B.  Thomas, 
M.  D.,  Visiting  Physician  to  the  Home  for  Friendless  Women  and  Children 
and  to  the  Newsboys'  Home ;  Assistant  Visiting  Physician  to  the  Kings 
County  Hospital;  Assistant  Bacteriologist,  Brooklyn  Health  Department. 
Price,  Cloth,  ^1.50    (Send  for  specimen  List.) 

One  hundred  and  sixty  detachable  (perforated)  diet  lists  for  Albuminuria, 
Anaemia  and  Debility,  Constipation,  Diabetes,  Diarrhoea,  Dyspepsia,  Fevers, 
Gout  or  Uric-Acid  Diathesis,  Obesity,  and  Tuberculosis.  Also  forty  detachable 
sheets  of  Sick-Room  Dietary,  containing  full  instructions  for  preparation  of 
easily-digested  foods  necessary  for  invalids.  Each  list  is  numbered  only,  the 
disease  for  which  it  is  to  be  used  in  no  case  being  mentioned,  an  index  key 
being  reserved  for  the  physician's  private  use. 

DIETS  FOR  INFANTS  AND  CHILDREN  IN  HEALTH  AND 
IN  DISEASE.  By  Louis  Starr,  M.  D.,  Editor  of  "An  American 
Text-Book  of  the  Diseases  of  Children."  230  blanks  (pocket-book  size), 
perforated  and  neatly  bound  in  flexible  morocco.     Price,  ^1.25  net. 

The  first  series  of  blanks  are  prepared  for  the  first  seven  months  of  infant 
life ;  each  blank  indicates  the  ingredients,  but  not  the  quantities,  of  the  food, 
the  latter  directions  being  left  for  the  physician.  After  the  seventh  month, 
modifications  being  less  necessary,  the  diet  lists  are  printed  in  full.  Formula 
fo'  tfte  preparation  of  diluents  and  foods  are  appended. 


CATALOGUE   OF  MEDICAL    WORKS.  35 

HOW  TO  EXAMINE  FOR  LIFE  INSURANCE.  By  John  M. 
Keating,  M.  D.,  Fellow  of  the  College  of  Physicians  and  Surgeons  of 
Philadelphia;  Vice-President  of  the  American  Paediatric  Society;  Ex- 
President  of  the  Association  of  Life  Insurance  Medical  Directors.  Royal 
8vo,  211  pages,  with  two  large  half-tone  illustrations,  and  a  plate  prepared 
by  Dr.  McClellan  from  special  dissections ;  also,  numerous  cuts  to  elucidate 
the  text.     Third  edition.      Price,  Cloth,  ^2.00  net. 

"  This  is  by  far  the  most  useful  book  v/hich  has  yet  appeared  on  insurance  examination,  a 
subject  of  growing  interest  and  importance.  Not  the  least  valuable  portion  of  the  volume  is 
Part  II.,  which  consists  of  instructions  issued  to  their  examining  physicians  by  twenty-four 
representative  companies  of  this  country.  As  the  proofs  of  these  instructions  were  corrected 
by  the  directors  of  the  companies,  they  form  the  latest  instructions  obtainable.  If  for  these 
alone,  the  book  should  be  at  the  right  hand  of  every  physician  interested  in  this  special  branch 
of  medical  science." — The  Medical  News,  Philadelphia. 

NURSING:    ITS    PRINCIPLES   AND    PRACTICE.      By   Isabel 

Adams  Hampton,  Graduate  of  the  New  York  Training  School  for 
Nurses  attached  to  Bellevue  Hospital;  Superintendent  of  Nurses  and 
Principal  of  the  Training  School  for  Nurses,  Johns  Hopkins  Hospital, 
Baltijnore,  Md. ;  late  Superintendent  of  Nurses,  Illinois  Training  School 
for  Nurses,  Chicago,  111.  In  one  very  handsome  i2mo  volume  of  512 
pages,  illustrated.     Price,   Cloth,  $2.00   net. 

SECOND   EDITION,  REVISED  AND  ENLARGED. 

This  original  work  on  the  important  subject  of  nursing  is  at  once  comprehensive 
and  systematic.  It  is  written  in  a  clear,  accurate,  and  readable  style,  suitable 
alike  to  the  student  and  the  lay  reader.  Such  a  work  has  long  been  a  desidera- 
tum with  those  entrusted  with  the  management  of  hospitals  and  the  instruction  of 
nurses  in  training-schools.  It  is  also  of  especial  value  to  the  graduated  nurse 
who  desires  to  acquire  a  practical  working  knowledge  of  the  care  of  the  si^.v 
and  the  hygiene  of  the  sick-room. 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERA- 
TIONS. By  L.  Ch.  Boisliniere,  M.  D.,  late  Emeritus  Professor  of 
Obstetrics  in  the  St.  Louis  Medical  College.  381  pages,  handsomely  illus- 
trated.    Price,  ^2.00  net. 

"  For  the  use  of  the  practitioner  who,  when  away  from  home,  has  not  the 
opportunity  of  consulting  a  library  or  of  calling  a  friend  in  consultation.  He 
then,  being  thrown  upon  his  own  resources,  will  find  this  book  of  benefit  in 
guiding  and  assisting  him  in  emergencies." 

INFANT'S  WEIGHT  CHART.  Designed  by  J.  P.  Crozer  Griffith, 
M.  D.,  Clinical  Professor  of  Diseases  of  Children  in  the  University  of  Peni> 
sylvania.    25  charts  in  each  pad.     Price  per  pad,  50  cents  net. 

A  convenient  blank  for  keeping  a  record  of  the  child's  weight  during  the  first 
two  years  of  life.  Printed  on  each  chart  is  a  curve  representing  the  average  weight 
of  a  healthy  infant,  so  that  any  deviation  from  the  normal  can  readily  be  detected. 


Saunders^ 
New  Series 
OF  Manuals 


for  Students 
and 
Practitioners* 


THAT  there  exists  a  need  for  thoroughly  reliable  hand-books  on  the  leading 
branches  of  Medicine  and  Surgery  is  a  fact  amply  demonstrated  by  the 
favor  with  which  the  SAUNDERS  NEW  SERIES  OF  MANUALS  have  been 
received  by  medical  students  and  practitioners  and  by  the  Medical  Press. 
These  manuals  are  not  merely  condensations  from  present  literature,  but 
are  ably  w^ritten  by  well-known  authors  and  practitioners,  most  of  them  being 
teachers  in  representative  American  colleges.  Each  volume  is  concisely  and 
authoritatively  written  and  exhaustive  in  detail,  w^ithout  being  encumbered 
•with  the  introduction  of  "cases,"  which  so  largely  expand  the  ordinary  text- 
book. These  manuals  will  therefore  form  an  admirable  collection  of  advanced 
lectures,  useful  alike  to  the  medical  student  and  the  practitioner:  to  the  latter, 
too  busy  to  search  through  page  after  page  of  elaborate  treatises  for  what  he 
wants  to  know,  they  will  prove  of  inestimable  value  ;  to  the  former  they  will 
afford  safe  guides  to  the  essential  points  of  study. 

The  SAUNDERS  NEW  SERIES  0¥  MANUALS  are  conceded  to  be 
superior  to  any  similar  books  now  on  the  market.  No  other  manuals  afford  so 
much  information  in  such  a  concise  and  available  form.  A  liberal  expenditure 
has  enabled  the  publisher  to  render  the  mechanical  portion  of  the  work  w^orthy 
of  the  high  literary  standard  attained  by  these  books. 

Any  of  these  Manuals  will  be  mailed  on  receipt  of  price  (see  next  page 
for  List). 


SAUNDERS'  NEW  SERIES  OF  MANUALS. 


VOLUMES  PUBLISHED. 


PHYSIOLOGY.     By  Joseph  Howard  Raymond,  A.  M.,  M.  D.,  Professor 

of  Physiology  and  Hygiene  and  Lecturer  on  Gynecology  in  the  Long 
Island  College  Hospital,  etc.     Price,  ^1.25  net. 

SURGERY,  General   and  Operative.     By   John   Chalmers  DaCosta, 

M.  D.,  Professor  of  Clinical  Surgery,  Jefferson  Medical  College,  Philadel- 
phia. Second  edition,  revised  and  greatly  enlarged.  Octavo,  911  pages, 
386  illustrations.     Cloth,  ^4.00  net ;   Half-Morocco,  ^5.00  net. 

DOSE-BOOK  AND  MANUAL  OF  PRESCRIPTION-WRITING. 

By  E.  Q.  Thornton,  M.  D.,  Demonstrator  of  Therapeutics,  Jefferson 
Medical  College,  Philadelphia.     Price,  ^1.25  net. 

MEDICAL  JURISPRUDENCE.  By  Henry  C.  Chapman,  M.  D.,  Pro- 
fessor of  Institutes  of  Medicine  and  Medical  Jurisprudence  in  the  Jeffer- 
son Medical  College  of  Philadelphia,  etc.     Price,  ^1.50  net. 

SURGICAL  ASEPSIS.  By  Carl  Beck,  M.D.,  Surgeon  to  St.  Mark's 
Hospital  and  to  the  German  Poliklinik ;  Instructor  in  Surgery,  New  York 
Post-Graduate  Medical  School,  etc.     Price,  jli.25  net. 

MANUAL  OF  ANATOMY.  By  Irving  S.  Haynes,  M.D.,  Adjunct 
Professor  of  Anatomy  and  Demonstrator  of  Anatomy,  Medical  Department 
of  the  New  York  University,  etc.     Price,  $2.50  net. 

SYPHILIS  AND  THE  VENEREAL  DISEASES.  By  James 
Nevins  Hyde,  M.  D.,  Professor  of  Skin  and  Venereal  Diseases,  and 
Frank  H.  Montgomery,  M.  D.,  Lecturer  on  Dermatology  and  Genito- 
urinary Diseases  in  Rush  Medical  College,  Chicago.     Price,  ^2.50  net. 

PRACTICE  OF  MEDICINE.  By  George  Roe  Lockwood,  M.  D., 
Professor  of  Practice  in  the  Woman's  Medical  College  of  the  New  York 
Infirmary,  etc.     Price,  ^2.50  net. 

OBSTETRICS.  By  W.  A.  Newman  Dorland,  M.  D.,  Assistant  Demon- 
strator of  Obstetrics,  University  of  Pennsylvania;  Chief  of  Gynecological 
Dispensary,  Pennsylvania  Hospital.     Price,  $2.50  net. 

DISEASES  OF  WOMEN.  By  J.  Bland  Sutton,  F.  R.  C.  S.,  Assistant 
Surgeon  to  the  Middlesex  Hospital,  and  Surgeon  to  the  Chelsea  Hospital 
forWomen,  London ;  and  Arthur  E.  Giles,  M,  D.,  B.  Sc.  Lond.,  F.  R.  C.  S. 
Edin.,  Assistant  Surgeon  to  the  Chelsea  Hospital  for  Women,  London.  436 
pages,  handsomely  illustrated.     Price,  ^2.50  net. 

IN    PREPARATION. 

NERVOUS  DISEASES.  By  Charles  W.  Burr,  M.  D.,  Clinical  Profes- 
sor of  Nervous  Diseases,  Medico-Chirurgical  College,  Philadelphia,  etc. 

*.j^*  There  will  be  published  in  the  same  series,  at  short  intervals,  carefully  prepared  works 
on  various  subjects,  by  prominent  specialists. 

37 


SAUNDERS'  QUESTION  COIVIPENDS. 

Arranged  in  Question  and  Answer  Form. 

THE  LATEST,  MOST  COMPLETE,  and  BEST  ILLUSTRATED 
SERIES  OF  COMPENDS  EVER  ISSUED. 


Now  the  Standard  Authorities  in  Medical  Literature 


WITH 


Students  and  Practitioners  in  every  City  of  the  United 
States  and  Canada. 


THE   REASON   WHY. 

They  are  the  advance  guard  of  "  Student's  Helps  " — that  do  help;  they  are 
the  leaders  in  their  special  line,  well  and  authoritatively  written  by  able  men, 
who,  as  teachers  in  the  large  colleges,  know  exactly  what  is  wanted  by  a  student 
prepai'ing  for  his  examinations.  The  judgment  exercised  in  the  selection  of 
authors  is  fully  demonstrated  by  their  professional  elevation.  Chosen  from  the 
ranks  of  Demonstrators,  Quiz-masters,  and  Assistants,  most  of  them  have  be- 
come Professors  and  Lecturers  in  their  respective  colleges. 

Each  book  is  of  convenient  size  (5x7  inches),  containing  on  an  average  250 
pages,  profusely  illustrated,  and  elegantly  printed  in  clear,  readable  type,  on 
fine  paper. 

The  entire  series,  numbering  twenty- four  subjects,  has  been  kept  thoroughly 
revised  and  enlarged  when  necessary,  many  of  them  being  in  their  fourth  and 
fifth  editions. 

TO   SUM    UP. 

Although  there  are  numerous  other  Quizzes,  Manuals,  Aids,  etc.  in  the  mar- 
ket, none  of  them  approach  the  "Blue  Series  of  Question  Compends;"  and 
the  claim  is  made  for  the  following  points  of  excellence : 

1.  Professional  distinction  and  reputation  of  authors. 

2.  Conciseness,  clearness,  and  soundness  of  treatment. 

3.  Size  of  type  and  quality  of  paper  and  binding. 

*^*  Any  of  these  Compends  will  be  mailed  on  receipt  of  price  (see  next 

page  for  List). 

38 


SAUNDERS'  QUESTION-COMPEND  SERIES. 


Price,  Cloth,  $J.OO  per  copy,  except  when  otherwise  noted. 

1.  ESSENTIALS  OF  PHYSIOLOGY.    4th  edition.    Illustrated.    Revised  and  enlarged 

By  H.  A.  Hare,  M.  D.     (Price,  $1.00  net.) 

2.  ESSENTIALS  OF  SURGERY.     6th  edition,  with  an  Appendix  on  Antiseptic  Sur- 

gery.    90  illustrations.     By  Edward  Martin,  M.  D. 

3.  ESSENTIALS  OF    ANATOMY.     5th  edition,  with  an  Appendix.     180  illustrations. 

By  Charles  B.  Nancrede,  M.  D. 

4.  ESSENTIALS  OF  MEDICAL  CHEMISTRY,  ORGANIC  AND  INORGANIC. 

4th  edition,  revised,  with  an  Appendix.     By  Lawrence  Wolff,  ^l.  D. 

5.  ESSENTIALS  OF  OBSTETRICS.     4th  edition,  revised  and  enlarged.      75  illustra- 

tions.    By  W.  Easterly  Ashton,  M.  D. 

6.  ESSENTIALS  OF  PATHOLOGY  AND  MORBID  ANATOMY.     7th  thousand. 

46  illustrations.     By  C.  E.  Armand   Semple,  M.  D. 

7.  ESSENTIALS    OF    MATERIA      MEDICA,     THERAPEUTICS,    AND    PRE- 

SCRIPTION-WRITING.     5th  edition.      By  Henry  Morris,  M.  D. 

8,9.  ESSENTIALS  OF  PRACTICE     OF    MEDICINE.      By  Henry  Morris,  M.D. 

An  Appendix  on  Urine  Examin  ation.  Illustrated.  By  Lawrence  Wolff,  M.  D. 
3d  edition,  enlarged  by  some  300  Essential  Formulae,  selected  from  eminent  authori- 
ties, by  Wm.  M.  Powell,  M.  D  .     (Double  number,  price  ^2.00.) 

10.  ESSENTIALS  OF  GYNiECOLOGY.     4th  edition,  revised.     With  62  illustrations. 

By  Edwin  B.  Cragin,  M.  D. 

11.  ESSENTIALS  OF  DISEASES  OF    THE  SKIN.    3d  edition,  revised  and  enlarged. 

71  letter-press  cuts  and  15  half-tone  illustrations.  By  Henry  W.  Stelwagon,  M.D. 
(Price,  $1.00  net.) 

12.  ESSENTIALS  OF  MINOR    SURGERY,  BANDAGING,  AND  VENEREAL 

DISEASES.  2d  edition,  revised  and  enlarged.  78  illustrations.  By  Edward 
Martin,  M.  D. 

13.  ESSENTIALS  OF  LEGAL    MEDICINE,  TOXICOLOGY,  AND    HYGIENE. 

130  illustrations.     By  C.  E.   Armand  Semple,  M.  D. 

14.  ESSENTIALS  OF  DISEASES  OF   THE  EYE,  NOSE,  AND  THROAT.    124 

illustrations.  2d  edition,  revised.  By  Edward  Jackson,  M.  D.,  and  E.  Baldwin 
Gleason,  M.  D. 

15.  ESSENTIALS  OF    DISEASES  OF  CHILDREN.     2d  edition.     By  William  M. 

Powell,  M.D. 

16.  ESSENTIALS  OF  EXAMINATION    OF    URINE.      Colored   "  Vogel  Scale," 

and  numerous  illustrations.     By   Lawrence  Wolff,  M.D.     (Price,  75  cents.) 

17.  ESSENTIALS  OF    DIAGNOSIS.     55    illustrations,  some  in  colors.     By  S.  Solis- 

CoHEX,  M.  D.,  and  A.  A.  Eshner,  M.  D.     (Price,  $1.50  net.) 

18.  ESSENTIALS  OF   PRACTICE  OF  PHARMACY.     2d  edition,  revised.     By  L. 

E.  Sayre. 

20.  ESSENTIALS  OF  BACTERIOLOGY.      3d   edition.     82   illustrations.     By  M.  V. 

Ball,  M.D. 

21.  ESSENTIALS  OF  NERVOUS  DISEASES  AND  INSANITY.    48  illustrations. 

3d  edition,  revised.     By  John  C.  Shaw,  M.  D. 

22.  ESSENTIALS  OF  MEDICAL  PHYSICS.     155  illustrations.     2d  edition,  revised. 

By  Fred  J.  Bkockway,  M.  D.     (Price,  $1.00  net.) 

23.  ESSENTIALS  OF  MEDICAL  ELECTRICITY.     65  illustrations.     By  David  D. 

Stewart,  M.  D.,  and  Edward  S.  Lawrance,  M.  D. 

24.  ESSENTIALS  OF  DISEASES  OF  THE  EAR.     114  illustrations.    2d  edition,  re- 

vised and  enlarged.     By  E.  Baldwin  Gleason,  M.  D. 

39 


IN   PREPARATION. 

THE  INTERNATIONAL  TEXT=BOOK  OF  SURGERY.     In  two  volumes. 

By  American  and  British  authors.  Edited  by  J.  Collins  Warren,  M.D.,  LL.D.,  Pro- 
fessor of  Surgery,  Harvard  Medical  School,  Boston;  Surgeon  to  ttie  Massachusetts 
General  Hospital;  and  A.  Pearce  Gould,  M.  S.,  F.  R.  C.  S.,  England,  Lecturer  on 
Practical  Surgery  and  Teacher  of  Operative  Surgery,  Middlesex  Hospital  Medical 
School ;  Surgeon  to  the  Middlesex  Hospital,  London,  England. 

AN  AMERICAN  TEXT=BOOK  OF  PATHOLOGY. 

Edited  by  John  Guiteras,  M.  D.,  Professor  of  General  Pathology  and  of  Morbid 
Anatomy,  University  of  Pennsylvania  ;  and  David  Riesman,  M.  D.,  Demonstrator  of 
Pathological  Histology,  University  of  Pennsylvania. 

AN  AMERICAN  TEXT=BOOK  OF  LEGAL  MEDICINE  AND  TOXICOLOGY. 

Edited  by  Frederick  Peterson,  M.  D.,  Clinical  Professor  of  Mental  Diseases, 
Woman's  Medical  College,  New  York;  and  Walter  S.  Haines,  M.  D.,  Professor 
of  Chemistry,  Pharmacy,  and  Toxicology,  Rush  Medical  College,  Chicago. 

AN  AMERICAN  TEXT=BOOK  OF  DIAGNOSIS. 

Edited  by  Alfred  Stengel,  M.  D.,  Physician  to  the  Philadelphia  Hospital;  Professor 
of  Clinical  Medicine  in  the  Woman's  Medical  College ;  Physician  to  the  Children's  Hos- 
pital;  late  Pathologist  to  the  German  Hospital,  Philadelphia,  etc. 

AN  AMERICAN  TEXT=BOOK  OF  CHEMISTRY. 

Edited  by  Herbert  M.  Hill,  Ph.D.,  Professor  of  Chemistry,  Toxicology,  and  Physics, 
Medical  Department  of  the  University  of  Buffalo,  New  York. 

AN  AMERICAN  TEXT=BOOK  OF  NURSING. 

By  American  Teachers.  Edited  by  Roberta  M.  West,  late  Superintendent  of 
Nurses  in  the  Hospital  of  the  University  of  Pennsylvania. 

KYLE  ON  THE  NOSE  AND  THROAT. 

Diseases  of  the  Nose  and  Throat.  By  D.  Braden  Kyle,  M.  D.,  Clinical  Professor 
of  Laryngology  and  Rhinology,  Jefferson  Medical  College,  Philadelphia. 

HEISLER'S  EMBRYOLOGY. 

A  Text=Book  of  Embryology.  By  John  C.  Heisler,  M.  D.,  Professor  of  Anatomy 
in  the  Medico-Chirurgical  College,  Philadelphia. 

PRYOR— PELVIC  INFLAMMATIONS. 

The  Treatment  of  Pelvic  Inflammations  through  the  Vagina.     By  W.  R.  Prycr, 

M.  D.,  Professor  of  Gynecology  in  the  New  York  Polj'clinic. 

VECKI-SEXUAL  IMPOTENCE. 

The  Pathology  and  Treatment  of  Sexual  Impotence.     By  Victor  G.  Vecki,  M.  D. 

From  the  second  German  Edition,  revised  and  enlarged. 

JACKSON— DISEASES  OF  THE  EYE. 

A  Manual  of  Diseases  of  the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor 
of  Diseases  of  the  Eye  in  the  Philadelphia  Polyclinic  and  College  for  Graduates  in 
Medicine. 

NANCREDE— PRINCIPLES  OF  SURGERY. 

The  Principles  of  Surgery.  By  Charles  B.  Nancrede,  M.D.,  Professor  of  Sur- 
gery and  of  Clinical  Surgery,  University  of  Michigan,  Ann  Arbor. 

OGDEN— URINARY  ANALYSIS. 

A  Manual  of  Urinary  Analysis.  By  J.  Bergen  Ogden,  M.  D.,  Assistant  in  Chem- 
istry, Harvard  University  Medical  School,  Boston,  Mass. 

STONEY— MATERIA  MEDICA  FOR  NURSES. 

Materia  Medica  for  Nurses.  By  Emily  A.  M.  Stoney,  Graduate  of  the  Training 
School  for  Nurses,  Lawrence,  Mass.  ;  late  Superintendent  of  the  Training  School  for 
Nurses,  Carney  Hospital,  South  Boston,  Mass. 

40 


SAUNDERS' 

MEDICAL  HAND-ATLASES. 

The  series  of  books  included  under  this  title  are  authorized  translations 
into  English  of  the  world-famous 

Lehmann  Medicinischc  Handatlanten, 

which  for  scientific  accuracy,  pictorial  beauty,  compactness,  and 
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Each  volume  contains  from  50  to  100  colored  plates,  besides  numer- 
ous illustrations  in  the  text.  The  colored  plates  have  been  executed  by  the 
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One  of  the  most  valuable  features  of  these  atlases  is  that  they  offer  a 
ready  and  satisfactory  substitute  for  clinical  observation.  Such  ob- 
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The  same  careful  and  competent  editorial  supervision  has  been 
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MEDICAL   HAND-ATLASES. 


Atlas  of  Internal  Medicine  and  Clinical  Diagnosis.    By 

Dr.  Chr.  Jakob,  of  JErlangen.     Edited  by  Augustus  A. 

t  COLUMBIA  UNIVERSITY 

^    This  book  is  due  on  the  date  indicated  below,  or  at  the 
At    expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
]    rangement  with  the  Librarian  in  charge. 


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Atlas  of  General  Surgery. 


Atlas  of  Diseases  of  the  Ear. 


Be  sure  to  see  it  Over  25,000  words> 

THE 

AMERICAN  POCKET  MEDICAL  DICTIONARY. 


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Price,  $1.25  net.  925  WALNUT  STREET,  PHILADELPHIA. 


